CollaborativePractice

The following is the Missouri State Regulation on Collaborative Practice.
For a suggested sample of a Collaborative Practice Agreement,
CLICK HERE.

CODE OF STATE MATT BLUNT (5/31/03) REGULATIONS 1
Secretary of State
Rules of
Department of Economic
Development
Division 150 State Board of Registration
for the Healing Arts
Chapter 5 eneral Rules

4 CSR 150-5.100 Collaborative Practice
PURPOSE: This rule defines collaborative
practice arrangement terms and delimits geographic
areas; methods of treatment; review
of services; and drug/device dispensing or
distribution pursuant to prescription.

CODE OF STATE MATT BLUNT (5/31/03) REGULATIONS 3
Secretary of State
Chapter 5 General Rules 4 CSR 150-5

(1) For the purpose of these rules, the following
definitions shall apply:

(A) Advanced practice nurse

A registered

professional nurse who is also an advanced

practice nurse as defined in section

335.016(2), RSMo;

(B) Collaborative practice arrangements

refers to written agreements, jointly agreed

upon protocols, or standing orders, all of

which shall be in writing, for the delivery of

health care services; and

A registered

professional nurse as defined in section

335.016(9), RSMo, who is not an

advanced practice nurse.

(2) Geographic Areas.

(A) The collaborating physician in a collaborative

practice arrangement shall not be

so geographically distanced from the collaborating

registered professional nurse or

advanced practice nurse as to create an

impediment to effective collaboration in the

delivery of health care services or the adequate

review of those services.

(B) The use of a collaborative practice

arrangement by an advanced practice nurse

who provides health care services that

include the diagnosis and initiation of treatment

for acutely or chronically ill or injured

persons shall be limited to practice locations

where the collaborating physician, or other

physician designated in the collaborative

practice arrangement, is no further than fifty

(50) miles by road, using the most direct

route available, from the collaborating

advanced practice nurse if the advanced practice

nurse is practicing in federally designated

health professional shortage areas

(HPSAs). Otherwise, in non-HPSAs, the collaborating

physician and collaborating

advanced practice nurse shall practice within

thirty (30) miles by road of one another. The

provision of the above specified health care

services pursuant to a collaborative practice

arrangement shall be limited to only an

advanced practice nurse.

desires to enter into a collaborative practice

arrangement to provide health care services

that include the diagnosis and treatment of

acutely or chronically ill or injured persons at

a location where the collaborating physician

is not continuously present shall practice at

the same location with the collaborating

physician for a period of at least one (1) calendar

month before the collaborating

advanced practice nurse practices at a location

where the collaborating physician is not

present. The provision of the above specified

health care services pursuant to a collaborative

practice arrangement shall be limited to

only an advanced practice nurse. This provision

applies to all collaborative practice

arrangements between a physician and an

advanced practice nurse unless a waiver is

obtained as provided in 4 CSR 150-

5.100(2)(D).

(D) If an advanced practice nurse has been

continuously providing health care services

pursuant to a collaborative practice arrangement

with the same physician for at least one

(1) year and the collaborating physician terminates

the collaborative practice arrangement

with less than thirty (30) days notice for

reasons unrelated to the advanced practice

nurse, 4 CSR 150-5.100(2)(C) may be

waived by the board of nursing and the board

of healing arts if the requirement for one (1)

calendar month same-site collaboration

would result in health care services at the

location where the advanced practice nurse

practices being discontinued or reduced. The

request for the waiver with supporting documentation

shall be submitted to the board of

nursing or the board of healing arts by the

advanced practice nurse or the collaborating

physician and shall specify all information

necessary for the board of nursing and the

board of healing arts to evaluate the request

including, but not limited to, the date and

reasons for the termination of the collaborative

practice arrangement, number of patients

affected and plan for a new collaborative

practice arrangement.

(3) Methods of Treatment.

(A) The methods of treatment and the

authority to administer, dispense, or prescribe

drugs delegated in a collaborative

practice arrangement between a collaborating

physician and collaborating registered professional

nurse or advanced practice nurse shall

be within the scope of practice of each professional

and shall be consistent with each

professional’s skill, training, education, and

competence.

(B) The collaborating physician shall consider

the level of skill, education, training,

and competence of the collaborating registered

professional nurse or advanced practice

nurse and ensure that the delegated responsibilities

contained in the collaborative practice

arrangement are consistent with that level of

skill, education, training, and competence.

authority to administer, dispense, or prescribe

drugs delegated to the collaborating

registered professional nurse or advanced

practice nurse in a collaborative practice

arrangement shall also be consistent with the

scope of practice of the collaborating physician.

(D) Guidelines for consultation and referral

to the collaborating physician or designated

health care facility for services or emergency

care that is beyond the education,

training, competence, or scope of practice of

the collaborating registered professional

nurse or advanced practice nurse shall be

established in the collaborative practice

arrangement.

(E) The methods of treatment and authority

to administer, dispense, or prescribe drugs

delegated to the collaborating registered professional

nurse or advanced practice nurse in

a collaborative practice arrangement shall not

be further delegated to any other person

except that the individuals identified in sections

338.095 and 338.198, RSMo may communicate

prescription drug orders to a pharmacist.

(F) The methods of treatment, including

any authority to administer or dispense

drugs, delegated in a collaborative practice

arrangement between a collaborating physician

and a collaborating registered professional

nurse shall be delivered only pursuant

to a written agreement, jointly agreed-upon

protocols, or standing orders that shall

describe a specific sequence of orders, steps,

or procedures to be followed in providing

patient care in specified clinical situations.

(G) The methods of treatment, including

any authority to administer, dispense, or prescribe

drugs, delegated in a collaborative

practice arrangement between a collaborating

physician and a collaborating advanced practice

nurse shall be delivered only pursuant to

a written agreement, jointly agreed upon protocols,

or standing orders that are specific to

the clinical conditions treated by the collaborating

physician and collaborating advanced

practice nurse.

(H) The collaborative practice arrangement

between a collaborating physician and a collaborating

registered professional nurse or

advanced practice nurse shall be signed and

dated by the collaborating physician and collaborating

registered professional nurse or

advanced practice nurse before it is implemented,

signifying that both are aware of its

content and agree to follow the terms of the

collaborative practice arrangement. The collaborative

practice arrangement and any subsequent

notice of termination of the collaborative

practice arrangement shall be in

writing and shall be maintained by the collaborating

professionals for a minimum of

eight (8) years after termination of the collaborative

practice arrangement. The collaborative

practice arrangement shall be reviewed

and revised as needed by the collaborating

physician and collaborating registered professional

nurse or advanced practice nurse.

(I) Methods of treatment delegated and

authority to administer, dispense, or prescribe

drugs shall be subject to the following:

1. The physician retains the responsibility

for ensuring the appropriate administering,

dispensing, prescribing and control of

drugs utilized pursuant to a collaborative

practice arrangement in accordance with all

state and federal statutes, rules, or regulations;

2. All labeling requirements outlined in

section 338.059, RSMo shall be followed;

3. Consumer product safety laws and

Class B container standards shall be followed

when packaging drugs for distribution;

4. All drugs shall be stored according to

the United States Pharmacopeia (USP) recommended

conditions, which is incorporated

by reference;

5. Outdated drugs shall be separated

from the active inventory;

6. Retrievable dispensing logs shall be

maintained for all prescription drugs dispensed

and shall include all information

required by state and federal statutes, rules,

or regulations;

7. All prescriptions shall conform to all

applicable state and federal statutes, rules, or

regulations and shall include the name,

address, and telephone number of the

collaborating physician and collaborating

advanced practice nurse;

8. A registered professional nurse shall

not, under any circumstances, prescribe

drugs;

9. An advanced practice nurse shall not,

under any circumstances, prescribe controlled

substances. The administering or dispensing

of a controlled substance by a registered

professional nurse or advanced practice

nurse in a collaborative practice arrangement

shall be accomplished only under the direction

and supervision of the collaborating

physician, or other physician designated in

the collaborative practice arrangement, and

shall only occur on a case-by-case determination

of the patient

s needs following verbal

consultation between the collaborating physician

and collaborating registered professional

nurse or advanced practice nurse. The

required consultation and the physician’s

directions for the administering or dispensing

of controlled substances shall be recorded in

the patient

s chart and in the appropriate dispensing

log. These recordings shall be made

by the collaborating registered professional

nurse or advanced practice nurse and shall be

cosigned by the collaborating physician following

a review of the records;

10. An advanced practice nurse or registered

professional nurse in a collaborative

practice arrangement may only dispense

starter doses of medication to cover a period

of time for seventy-two (72) hours or less

with the exception of Title X family planning

providers or publicly funded clinics in community

health settings that dispense medications

free of charge. The dispensing of drug

samples, as defined in 21 U.S.C. section 353

(c)(1), is permitted as appropriate to complete

drug therapy; and

11. The medications to be administered,

dispensed, or prescribed by a collaborating

registered professional nurse or advanced

practice nurse in a collaborative practice

arrangement shall be consistent with the education,

training, competence, and scopes of

practice of the collaborating physician and

collaborating registered professional nurse or

advanced practice nurse.

(J) When a collaborative practice arrangement

is utilized to provide health care services

for conditions other than acute self-limited

or well defined problems, the

collaborating physician, or other physician

designated in the collaborative practice

arrangement, shall see the patient for evaluation

and approve or formulate the plan of

treatment for new or significantly changed

conditions as soon as is practical, but in no

case more than two (2) weeks after the patient

has been seen by the collaborating advanced

practice nurse or registered professional

nurse.

(K) Nothing in these rules shall be construed

to permit medical diagnosis of any

condition by a registered professional nurse

pursuant to a collaborative practice arrangement.

(4) Review of Services.

(A) In order to assure true collaborative

practice and to foster effective communication

and review of services, the collaborating

physician, or other physician designated in

the collaborative practice arrangement, shall

be immediately available for consultation to

the collaborating registered professional

nurse or advanced practice nurse at all times,

either personally or via telecommunications.

(B) The collaborating physician shall

review the work, records, and practice of the

health care delivered pursuant to a collaborative

practice arrangement at least once every

two (2) weeks. This review shall be documented

by the collaborating physician. This

subsection shall not apply to the situation

described in subsection (4)(E) below or during

the time the collaborating physician and

collaborating advanced practice nurse are

practicing together as required in subsection

(2)(C) above.

is used in clinical situations where a collaborating

advanced practice nurse provides

health care services that include the diagnosis

and initiation of treatment for acutely or

chronically ill or injured persons, then the

collaborating physician shall be present for

sufficient periods of time, at least once every

two (2) weeks, except in extraordinary circumstances

that shall be documented, to participate

in such review and to provide necessary

medical direction, medical services,

consultations, and supervision of the health

care staff. In such settings the use of a collaborative

practice arrangement shall be limited

to only an advanced practice nurse and

the physician shall not enter into a collaborative

practice arrangement with more than

three (3) full-time equivalent advanced practice

nurses.

(D) The collaborating physician and collaborating

registered professional nurse or

advanced practice nurse shall determine an

appropriate process of review and management

of abnormal test results which shall be

documented in the collaborative practice

arrangement.

(E) In the case of collaborating physicians

and collaborating registered professional

nurses or advanced practice nurses practicing

in settings which provide care to well patients

or to those with narrowly circumscribed conditions

in public health clinics or community

health settings that provide population-based

health services limited to immunizations,

well child care, human immunodeficiency

virus (HIV) and sexually transmitted disease

care, family planning, tuberculosis control,

cancer and other chronic disease and wellness

screenings, services related to epidemiologic

investigations and prenatal care, review

of services shall occur as needed and set forth

in the collaborative practice arrangement. If

the services provided in such settings include

diagnosis and the initiation of treatment of

any other disease or injury, then the provisions

of subsection (4)(C) shall apply.

(F) The process and documentation of

review shall be on file and maintained in the

collaborative practice setting.

(G) The Missouri State Board of Registration

for the Healing Arts and the Missouri

State Board of Nursing separately retain the

right and duty to discipline their respective

licensees for violations of any state or federal

statutes, rules, or regulations regardless of

the licensee’s participation in a collaborative

practice arrangement.

(5) Population-Based Public Health Services.

(A) In the case of the collaborating physicians

and collaborating registered professional

nurses or advanced practice nurses practicing

in association with public health clinics

that provide population-based health services

limited to immunizations, well child care,

HIV and sexually transmitted disease care,

family planning, tuberculosis control, cancer

and other chronic disease and wellness

screenings, services related to epidemiologic

investigations and related treatment, and prenatal

care, the geographic areas, methods of

treatment and review of services shall occur

as set forth in the collaborative practice

arrangement. If the services provided in such

settings include diagnosis and initiation of

treatment of disease or injury not related to

population-based health services, then the

provisions of sections (2), (3), and (4) above

shall apply.

AUTHORITY: sections 334.104.3, RSMo
Supp. 2002, and 334.125 and 335.036,
RSMo 2000.* Original rule filed Jan. 29,
1996, effective Sept. 30, 1996. Amended:
Filed April 1, 1998, effective Oct. 30, 1998.
Amended: Filed Oct. 30, 2002, effective June
30, 2003.
*Original authority: 334.104.3, RSMo 1993 amended
2002; 334.125, RSMo 1959, amended 1993, 1995; and
335.036, RSMo 1975, amended 1981, 1985, 1993, 1995,
1999.
6 CODE OF STATE REGULATIONS (5/31/03) MATT BLUNT
Secretary of State
4 CSR 150-5—DEPARTMENT OF Division 150—State Board of Registration
ECONOMIC DEVELOPMENT for the Healing Arts