Developing protocols with a nurse practitioner or physician assistant will require time and attention to detail, but it is one of the most important steps toward an effective, collegial and protective physician-PA/APRN relationship. Protocols are not “cookbook” recipes for managing clinical conditions, but are a method of ensuring an advanced practice provider (PA/APRN) is practicing at his/her highest level of competency and training within generally accepted specialty guidelines and legal authority. The protocol is generally an agreement between the PA/APRN and the physician for the purpose of defining the scope of prescriptive authority and other medical acts to be exercised by the PA/APRN in compliance with state law and the administrative rules and regulations promulgated by their respective licensing boards. Protocols allow them to utilize their assessment and health care management skills with a high degree of independence and in accordance with established standards. The effectiveness of the health care team is enhanced by empowering advanced practice providers to apply their knowledge and skills through the use of treatment protocols.
Most states allow nurse practitioners and physician assistants to perform certain functions such as diagnosing, treating and/or prescribing medications under protocols developed jointly with a licensed physician. Physicians must enter into a treatment protocol or collaborative practice agreement (CPA) with the PA/APRN Protocols are specific to the patient population and broadly the standard of care. Protocols must also include a method of consultation and referral, prescriptive privileges and medication formulary, plans for coverage of the healthcare needs of a patient in the emergency absence of the PA/APRN, and any required chart review or co-signature by the physician. Finally, collaborative practice agreements and protocols should be signed by both the physician and PA/APRN.
Often, each state’s protocol requirements are extensive and lengthy. Several state licensure boards including Alabama, Arkansas, Georgia, Kentucky, Mississippi and Virginia provide online sample protocols, collaborative practice agreements and templates or forms for prescriptive authority that may be used to comply with state. It’s important to consult the respective licensure board of each party to the agreement. Often, the medical board will have more regulations for collaboration with or supervision of advanced practice providers than the nursing board. However, in states without specific sample forms, templates or guidelines, the protocols should be specific to the patient population, define the scope of authority delegated to the PA/APRN and broadly outline the standard of care. Some states offer lists of medical guidelines that may be utilized. Check with your licensure board for specifics, but the minimum elements of a protocol agreement include:
Reference Guidelines for Practice
Protocols are not intended to provide a course of treatment for every condition in every patient. They are context dependent, giving the PA/APRN a range of condition specific protocols typically encompassing the services routinely provided in the course and scope of medical practice, as well as any additional procedures for which the PA/APRN has obtained specialized training and credentials. Simply adopting a text or other medical publication is generally not sufficient to meet state medical board standards. Examples of reference guidelines include the State Nurse Practice Act, journal articles, textbooks, approved procedure manuals, approved clinical research protocols, agency policies and procedures, online protocols such as Up to Date drug and laboratory references and other recognized medical standards of care.
Physician and Backup Physician Availability
There must be physician or backup physician availability at all times. The protocols/CPA should include a method of consultation with contact information.
Licensure and Similar Specialty
All states within the SVMIC service area require both the physician and PA/APRN to maintain a current, unencumbered license to practice in the state (typically retired physicians are ineligible). The supervising or collaborating physician must have experience and/or expertise in the same area of medicine as the PA/APRN. The APRN may have a limited scope of practice based on his or her education, training and national certification.
A protocol must be in place if a PA/APRN has been delegated prescriptive authority. Protocols should include a medication formulary of drugs and medical devices that are approved to be prescribed and/or issued by an authorized prescriber, which may include controlled substances.
Situations Requiring Consultation With the Physician
This section indicate when onsite evaluation or telephone consultation is required. Typically, situations that are not within the PA/APRN’s scope of practice: situations posing an immediate threat to the patient’s life; when a patient is referred for emergency management; conditions that fail to respond to the management plan within an appropriate time frame; findings that are unusual or unexplained; or whenever a patient requests physician consultation and in the event of an unexpected outcome.
The method of documentation, physician review and signature (if required) should be indicated. Generally, this will be defined in the board rules.
Review and Signature
Written protocols should be jointly developed, dated and signed by both the physician and PA/APRN.
Maintained at each practice location
Protocols/ and medication formulary must be available for inspection at all practice locations. You may develop a protocol that covers multiple practice locations and multiple relationships, but each supervisory/collaborative relationship must be captured individually by completing the forms in the licensure board.
Additionally, protocols may also cover the PA/APRN’s authority to delegate duties to other licensed or unlicensed personnel, how to handle patient requests to see a physician, a quality assurance plan if required (Mississippi) and other mutually agreed upon practice guidelines. Both the Tennessee and Georgia medical boards offer Frequently Asked Questions regarding supervision to include information on protocols which is a helpful “at a glance” tool.
Remember to update the protocols according to the board’s guidelines at least every other year (annually in Arkansas and Georgia), when there is a change in the relationship, or when new procedures are authorized after completion of advanced medical training. Keep in mind, the physician should always have experience or expertise similar that of the PA/APRN before signing off on procedures to be performed by them. Notice of any change or termination of a protocol or collaborative agreement must be given to the applicable boards within a defined time period which is found on the state board website.
Please see our page listing state-specific regulations. For questions or links to additional resources, please contact SVMIC.
 In Kentucky- APRNs are allowed to practice independently without a collaborative agreement. However, they must enter into a collaborative agreement with a physician in order to prescribe medications.
 See this resource on our website for more information on APP signatures in the EHR
Julie Loomis is Assistant Vice President of Risk Education for SVMIC where she develops educational programs and assists policyholders and staff with risk management issues. Ms. Loomis is a member of the Tennessee Bar Association and American Society of Healthcare Risk Managers (ASHRM). She serves on the Risk Management/Patient Safety Committee of the Medical Professional Liability Association. Ms. Loomis is a speaker on risk management and professional liability topics at industry seminars, medical schools and residency programs.
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