Advanced Practice Registered Nurse (APRN) Eligible to Engage in Prescriptive Practice

(1) Purpose. The purpose of 243 CMR 2.10 is to establish, pursuant to M.G.L. c. 112, §§ 80B, 80C, 80E, 80G, 80H and 80I and M.G.L. c. 94C, substantive standards governing the practice of medicine with respect to the supervision of Advanced Practice Registered Nurses (APRN) engaged in prescriptive practice. Such prescriptive practice is defined and regulated in 244 CMR 4.00: Advanced Practice Registered Nursing. (2) Advanced Practice Registered Nurses (APRN) Eligible to Engage in Prescriptive Practice. The following APRNs are eligible to register with the Department of Public Health pursuant to M.G.L. c. 94C and the U.S. DrugEnforcement Administration to engage in prescriptive practice. (a) A Certified Nurse Midwife (CNM) means a registered nurse authorized to practice as a certified nurse midwife by the Board of Registration in Nursing pursuant to M.G.L. c. 112, §§ 80B, 80C and 80G, and 244 CMR 4.00: Advanced Practice Registered Nursing. Written guidelines governing the practice of a nurse midwife engaged in prescriptive practice shall also comply with the requirements of M.G.L. c. 112, §§ 80C, and 244 CMR 4.00: Advanced Practice Registered Nursing. (b) A Certified Nurse Practitioner (CNP) means a registered nurse authorized to practice as a certified nurse practitioner by the Board of Registration in Nursing, pursuant to M.G.L. c. 112, §§ 80B and 80E, and 244 CMR 4.00: Advanced Practice Registered Nursing. (c) A Psychiatric Clinical Nurse Specialist (PCNS) means a registered nurse authorized to practice as a psychiatric clinical nurse specialist by the Board of Registration in Nursing, pursuant to M.G.L. c. 112, § 80B and 80E, and 244 CMR 4.00: Advanced Practice Registered Nursing. (d) A Certified Registered Nurse Anesthetist (CRNA) means a registered nurse authorized to practice as a nurse anesthetist by the Board of Registration in Nursing, pursuant to M.G.L. c. 112, §§ 80B and 80H, and 244 CMR 4.00: Advanced Practice Registered Nursing. (e) A Clinical Nurse Specialist (CNS) means a registered nurse authorized to practice as a clinical nurse specialist by the Board of Registration in Nursing, pursuant to M.G.L. c. 112, § 80B, and 244 CMR 4.00: Advanced Practice Registered Nursing. (3) Definitions. The following definitions apply only to 243 CMR 2.10. Guidelines mean written instructions and procedures describing the methods that an APRN with prescriptive practice is to follow when managing medications or resolving a health care problem and which specifies those instances in which referral to or consultation with a physician is required for appropriate medication management. Guidelines shall also address procedures for the ordering of tests and therapeutics when appropriate. Immediate Perioperative Care of a Patient means the period commencing on the day prior to surgery and ending upon discharge of the patient from post-anesthesia care. Prescriptive Practice means issuing written or oral prescriptions or medication orders for controlled substances pursuant to a valid registration from the Massachusetts Department of Public Health under M.G.L. c. 94C and, as appropriate, the U.S. Drug Enforcement Administration. Supervising Physician means a licensee holding an unrestricted full license in the Commonwealth who: (a) has completed training in the United States approved by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) or in Canada approved bythe Royal College of Physicians and Surgeons in Canada (RCPSC) in a specialty area appropriately related to the APRN's area of practice, is board certified in a specialtyarea appropriatelyrelated to the APRN's area of practice, or has hospital admitting privileges in a specialty area appropriately related to the APRN's area of practice. A physician who collaborates with a Certified Psychiatric Clinical Nurse Specialist shall have completed training in psychiatryapproved by the ACGME, AOA or the RCPSC, or be Board certified in psychiatry; (b) holds valid registration(s) to issue written or oral prescriptions or medication orders for controlled substances from the Massachusetts Department of Public Health and the U.S. Drug Enforcement Administration; (c) provides supervision to a certified nurse practitioner, a certified psychiatric clinical nurse specialist, or certified registered nurse anesthetist, as provided for in the applicable law or regulations of the Boards of Registration in Medicine and in Nursing (BORN) (244 CMR); (d) APRN signs mutually developed and agreed upon prescriptive practice guidelines with the APRN; and (e) reviews the prescriptive practice of a CNP, a PCNS or a CRNA as described in the guidelines. (4) Physician Supervision of an APRN Engaged in Prescriptive Practice. (a) A supervising physician shall review and provide ongoing direction for the APRN's prescriptive practice in accordance with written guidelines mutually developed and agreed upon with the APRN pursuant to 244 CMR: Board of Registration in Nursing and 243 CMR 2.10. This supervision shall be provided as is necessary, taking into account the education, training and experience of the APRN, the nature of the APRN's practice, and the physician's availability to provide clinical backup to ensure that the APRN is providing patient care in accordance with accepted standards of practice. (b) A supervising physician shall sign prescriptive practice guidelines only with those APRNs for whom he or she is able to provide supervision consistent with 243 CMR 2.10(2) and (3), taking into account factors including, but not limited to geographical proximity, practice setting, volume and complexity of the patient population, and the experience, training and availability of the supervising physician and the APRN(s). (c) A supervising physician shall not enter into guidelines, pursuant to 243 CMR 2.10, unless the APRN has professional malpractice liability insurance as required by 244 CMR 4.09: Malpractice Insurance. (5) Development, Approval, and Review of Guidelines for an APRN Engaged in Prescriptive Practice. (a) A physician who supervises an APRN engaged in prescriptive practice shall do so in accordance with written guidelines mutually developed and agreed upon with the APRN. (b) In all cases, the written guidelines shall: 1. identify the supervising physician and APRN; 2. include a defined mechanism for the delegation of supervision to another physician including, but not limited to, the duration and scope of the delegation; 3. describe the nature and scope of the APRN's prescribing practice; 4. identify the types of medication(s) to be prescribed, specify any limitations on medications to be prescribed; and describe the circumstances in which physician consultation or referral is required; 5. describe the use of established procedures for the treatment of common medical conditions which the nurse may encounter; 6. include provisions for managing emergencies; 7. include a defined mechanism and time frame to monitor prescribing practices; 8. include protocols for the initiation of intravenous therapies and Schedule II drugs; 9. specify that the initial prescription of Schedule II drugs must be reviewed within 96 hours; 10. specify that the guidelines must be kept on file in the workplace and be reviewed and reexecuted every two years; and 11. conform to M.G.L. c. 94C, 105 CMR 700.000: Implementation of M.G.L. C. 94C, M.G.L. c. 112, §§ 80B, 80C, 80E, 80G, 80H and 80I, and 244 CMR: Board of Registration in Nursing. (6) The Board may request at any time an opportunity to review the guidelines under which a physician is supervisingan APRN engaged in prescriptive practice. Failure to provide guidelines to the Board is a basis for and may result in disciplinary action. The Board may require changes in the guidelines if it determines that they do not comply with 243 CMR 2.10 and accepted standards of medical or nursing practice. The Board may also disapprove guidelines in their entirety if it determines that the supervising physician is incapable of providing adequate supervision to the APRN(s) engaged in prescriptive practice. (7) The Board may request at any time documentation of any review conducted by the supervising physician of the APRN engaged in prescriptive practice. Failure to provide documentation to the Board is a basis for and may result in disciplinary action.