334.104. Collaborative practice arrangements, form, contents, delegation of authority--rules, approval, restrictions--disciplinary actions--notice of collaborative practice or physician assistant agre
Collaborative practice arrangements, form, contents, delegation ofauthority--rules, approval, restrictions--disciplinaryactions--notice of collaborative practice or physician assistantagreements to board, when--certain nurses may provide anesthesiaservices, when--contract limitations.
334.104. 1. A physician may enter into collaborative practicearrangements with registered professional nurses. Collaborative practicearrangements shall be in the form of written agreements, jointlyagreed-upon protocols, or standing orders for the delivery of health careservices. Collaborative practice arrangements, which shall be in writing,may delegate to a registered professional nurse the authority to administeror dispense drugs and provide treatment as long as the delivery of suchhealth care services is within the scope of practice of the registeredprofessional nurse and is consistent with that nurse's skill, training andcompetence.
2. Collaborative practice arrangements, which shall be in writing,may delegate to a registered professional nurse the authority toadminister, dispense or prescribe drugs and provide treatment if theregistered professional nurse is an advanced practice nurse as defined insubdivision (2) of section 335.016, RSMo. Collaborative practicearrangements may delegate to an advanced practice registered nurse, asdefined in section 335.016, RSMo, the authority to administer, dispense, orprescribe controlled substances listed in Schedules III, IV, and V ofsection 195.017, RSMo; except that, the collaborative practice arrangementshall not delegate the authority to administer any controlled substanceslisted in schedules III, IV, and V of section 195.017, RSMo, for thepurpose of inducing sedation or general anesthesia for therapeutic,diagnostic, or surgical procedures. Schedule III narcotic controlledsubstance prescriptions shall be limited to a one hundred twenty-hoursupply without refill. Such collaborative practice arrangements shall bein the form of written agreements, jointly agreed-upon protocols orstanding orders for the delivery of health care services.
3. The written collaborative practice arrangement shall contain atleast the following provisions:
(1) Complete names, home and business addresses, zip codes, andtelephone numbers of the collaborating physician and the advanced practiceregistered nurse;
(2) A list of all other offices or locations besides those listed insubdivision (1) of this subsection where the collaborating physicianauthorized the advanced practice registered nurse to prescribe;
(3) A requirement that there shall be posted at every office wherethe advanced practice registered nurse is authorized to prescribe, incollaboration with a physician, a prominently displayed disclosurestatement informing patients that they may be seen by an advanced practiceregistered nurse and have the right to see the collaborating physician;
(4) All specialty or board certifications of the collaboratingphysician and all certifications of the advanced practice registered nurse;
(5) The manner of collaboration between the collaborating physicianand the advanced practice registered nurse, including how the collaboratingphysician and the advanced practice registered nurse will:
(a) Engage in collaborative practice consistent with eachprofessional's skill, training, education, and competence;
(b) Maintain geographic proximity; and
(c) Provide coverage during absence, incapacity, infirmity, oremergency by the collaborating physician;
(6) A description of the advanced practice registered nurse'scontrolled substance prescriptive authority in collaboration with thephysician, including a list of the controlled substances the physicianauthorizes the nurse to prescribe and documentation that it is consistentwith each professional's education, knowledge, skill, and competence;
(7) A list of all other written practice agreements of thecollaborating physician and the advanced practice registered nurse;
(8) The duration of the written practice agreement between thecollaborating physician and the advanced practice registered nurse;
(9) A description of the time and manner of the collaboratingphysician's review of the advanced practice registered nurse's delivery ofhealth care services. The description shall include provisions that theadvanced practice registered nurse shall submit a minimum of ten percent ofthe charts documenting the advanced practice registered nurse's delivery ofhealth care services to the collaborating physician for review everyfourteen days; and
(10) The collaborating physician shall review every fourteen days aminimum of twenty percent of the charts in which the advanced practiceregistered nurse prescribes controlled substances. The charts reviewedunder this subdivision may be counted in the number of charts required tobe reviewed under subdivision (9) of this subsection.
4. The state board of registration for the healing arts pursuant tosection 334.125 and the board of nursing pursuant to section 335.036, RSMo,may jointly promulgate rules regulating the use of collaborative practicearrangements. Such rules shall be limited to specifying geographic areasto be covered, the methods of treatment that may be covered bycollaborative practice arrangements and the requirements for review ofservices provided pursuant to collaborative practice arrangements includingdelegating authority to prescribe controlled substances. Any rulesrelating to dispensing or distribution of medications or devices byprescription or prescription drug orders under this section shall besubject to the approval of the state board of pharmacy. Any rules relatingto dispensing or distribution of controlled substances by prescription orprescription drug orders under this section shall be subject to theapproval of the department of health and senior services and the stateboard of pharmacy. In order to take effect, such rules shall be approvedby a majority vote of a quorum of each board. Neither the state board ofregistration for the healing arts nor the board of nursing may separatelypromulgate rules relating to collaborative practice arrangements. Suchjointly promulgated rules shall be consistent with guidelines for federallyfunded clinics. The rulemaking authority granted in this subsection shallnot extend to collaborative practice arrangements of hospital employeesproviding inpatient care within hospitals as defined pursuant to chapter197, RSMo, or population-based public health services as defined by 20 CSR2150-5.100 as of April 30, 2008.
5. The state board of registration for the healing arts shall notdeny, revoke, suspend or otherwise take disciplinary action against aphysician for health care services delegated to a registered professionalnurse provided the provisions of this section and the rules promulgatedthereunder are satisfied. Upon the written request of a physician subjectto a disciplinary action imposed as a result of an agreement between aphysician and a registered professional nurse or registered physicianassistant, whether written or not, prior to August 28, 1993, all records ofsuch disciplinary licensure action and all records pertaining to thefiling, investigation or review of an alleged violation of this chapterincurred as a result of such an agreement shall be removed from the recordsof the state board of registration for the healing arts and the division ofprofessional registration and shall not be disclosed to any public orprivate entity seeking such information from the board or the division.The state board of registration for the healing arts shall take action tocorrect reports of alleged violations and disciplinary actions as describedin this section which have been submitted to the National Practitioner DataBank. In subsequent applications or representations relating to hismedical practice, a physician completing forms or documents shall not berequired to report any actions of the state board of registration for thehealing arts for which the records are subject to removal under thissection.
6. Within thirty days of any change and on each renewal, the stateboard of registration for the healing arts shall require every physician toidentify whether the physician is engaged in any collaborative practiceagreement, including collaborative practice agreements delegating theauthority to prescribe controlled substances, or physician assistantagreement and also report to the board the name of each licensedprofessional with whom the physician has entered into such agreement. Theboard may make this information available to the public. The board shalltrack the reported information and may routinely conduct random reviews ofsuch agreements to ensure that agreements are carried out for complianceunder this chapter.
7. Notwithstanding any law to the contrary, a certified registerednurse anesthetist as defined in subdivision (8) of section 335.016, RSMo,shall be permitted to provide anesthesia services without a collaborativepractice arrangement provided that he or she is under the supervision of ananesthesiologist or other physician, dentist, or podiatrist who isimmediately available if needed. Nothing in this subsection shall beconstrued to prohibit or prevent a certified registered nurse anesthetistas defined in subdivision (8) of section 335.016, RSMo, from entering intoa collaborative practice arrangement under this section, except that thecollaborative practice arrangement may not delegate the authority toprescribe any controlled substances listed in Schedules III, IV, and V ofsection 195.017, RSMo.
8. A collaborating physician shall not enter into a collaborativepractice arrangement with more than three full-time equivalent advancedpractice registered nurses. This limitation shall not apply tocollaborative arrangements of hospital employees providing inpatient careservice in hospitals as defined in chapter 197, RSMo, or population-basedpublic health services as defined by 20 CSR 2150-5.100 as of April 30,2008.
9. It is the responsibility of the collaborating physician todetermine and document the completion of at least a one-month period oftime during which the advanced practice registered nurse shall practicewith the collaborating physician continuously present before practicing ina setting where the collaborating physician is not continuously present.This limitation shall not apply to collaborative arrangements of providersof population-based public health services as defined by 20 CSR 2150-5.100as of April 30, 2008.
10. No agreement made under this section shall supersede currenthospital licensing regulations governing hospital medication orders underprotocols or standing orders for the purpose of delivering inpatient oremergency care within a hospital as defined in section 197.020, RSMo, ifsuch protocols or standing orders have been approved by the hospital'smedical staff and pharmaceutical therapeutics committee.
11. No contract or other agreement shall require a physician to actas a collaborating physician for an advanced practice registered nurseagainst the physician's will. A physician shall have the right to refuseto act as a collaborating physician, without penalty, for a particularadvanced practice registered nurse. No contract or other agreement shalllimit the collaborating physician's ultimate authority over any protocolsor standing orders or in the delegation of the physician's authority to anyadvanced practice registered nurse, but this requirement shall notauthorize a physician in implementing such protocols, standing orders, ordelegation to violate applicable standards for safe medical practiceestablished by hospital's medical staff.
12. No contract or other agreement shall require any advancedpractice registered nurse to serve as a collaborating advanced practiceregistered nurse for any collaborating physician against the advancedpractice registered nurse's will. An advanced practice registered nurseshall have the right to refuse to collaborate, without penalty, with aparticular physician.
(L. 1993 H.B. 564, A.L. 2002 S.B. 1182, A.L. 2003 H.B. 390, A.L. 2006 H.B. 1515 merged with S.B. 756, A.L. 2008 S.B. 724, A.L. 2009 H.B. 247)