Collaborative Practice Rule

The State Board of Nursing’s and State Board of Registration for the Healing Arts’ joint rulemaking activity on collaborative practices by physicians with registered professional nurses (RNs) or registered professional nurses who are advanced practice nurses (APNs) became law on September 30, 1996.  This rule, 4 CSR 200-4.200 Collaborative Practice (Nursing) or 4 CSR 150-5.100 Collaborative Practice (Healing Arts), specifies the practice boundaries of physicians and RNs or physicians and APNs engaged in written collaborative practice arrangements.  You can access the Collaborative Practice Rule here.

Collaborative practice arrangements (CPAs) are defined in state statute (334.104 RSMo) as written agreements, jointly agreed-upon written protocols, or written standing orders for the delivery of health care services.  Through a CPA a physician may delegate:

• To an RN who is not an APN the authority to administer or dispense drugs and provide treatment within the RN’s scope or practice and consistent with the RN’s skill, training and competence; and
• To an RN who is an APN the authority to administer, dispense, and prescribe drugs and provide treatment.

An RN does not need to engage in a CPA with a physician nor require physician oversight to perform “nursing acts” the RN has the specialized education, judgment, and skill to perform [335.016 (9) (a) through (e) RSMo].  If the RN, however, is to perform delegated “medical acts“ (e.g., dispensing of drugs*), a physician-RN or physician-APN relationship must clearly and defensibly be in place.

A professional relationship between a physician and RN or APN can be established and exercised through the traditional means of specific, and later cosigned, verbal orders from a physician or written orders, possibly in the form of protocols or standing orders, generated and signed by a physician and carried out by an RN or APN.  In this case, the relationship is not based on a jointly agreed-upon practice arrangement and therefore, would not constitute a collaborative practice arrangement and the collaborative practice rule would not apply.

On the other hand, a physician-RN or physician-APN relationship can also be established and exercised through one or more of the jointly agreed-upon physician and RN or physician and APN written means described above.  In this case, a written collaborative practice arrangement exists and the collaborative practice rule applies.

Collaborating physicians and collaborating RNs or APNs practicing in association with public health clinics providing specific population-based health services must abide by the statute provisions in 334.104 RSMo and sections (1) and (5) only of the collaborative practice rule (4 CSR 200-4.200). The specific services are as follows:  immunizations; well child care; HIV and sexually transmitted disease care; family planning; tuberculosis control; cancer and other chronic diseases and wellness screenings; services related to epidemiological investigations and related treatment; and prenatal care.

If services provided in public health clinics include diagnosis and initiation of treatment of any other disease or injury than those listed above, then all other rule provisions [sections (2), (3), and (4)] apply. Although collaborating professionals whose practice activities meet the above population-based health services are not bound to address all the rule provisions in their written collaborative practice arrangements, they may find inclusion of other rule provisions to be in the best interest of reasonable, prudent, and defensible practice.

Additionally, some rule provisions are required practices pursuant to other state or federal laws whether or not one is in a written collaborative practice arrangement.  An example of this are several provisions regarding drug administration and dispensing behaviors in section (3) (I) of the Collaborative Practice Rule (4 CSR 200-4.200).