State by State Requirements
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      3. State by State Requirements

      Collaborating in Georgia

      Learn more about the requirements to collaborate and practice in Georgia

      State Regulations for Nurse Practitioners

      General

      • In which category does the state fall: NP independent practice, transition to independence, or collaboration required?
        • Collaboration required.

      Delegation Authority/Process

      • Is an agreement required?
        • Yes. In Georgia, the supervising physician is referred to as the "Delegating Physician".
      • What form of agreement is required and what are the requirements for the substance of the agreement?
        • The state strongly recommends using its form. Georgia Board of Nursing APRN Protocol Registration Forms.
        • Nurse protocol agreement must:
          • Be between an advanced practice registered nurse who is in a comparable specialty area or field as that of the delegating physician;
          • Contain a provision for immediate consultation between the APRN and the delegating physician; if the delegating physician is not available, the delegating physician for purposes of consultation may designate another physician who concurs with the terms of the nurse protocol agreement;
          • Identify the parameters under which delegated acts may be performed by the APRN, including without limitation the number of refills which may be ordered, the kinds of diagnostic studies which may be ordered, the extent to which radiographic imaging tests may be ordered, and the circumstances under which a prescription drug order may be executed. In the event the delegating physician authorizes the advanced practice registered nurse to order an X-ray, ultrasound, or radiographic imaging test, the nurse protocol agreement shall contain provisions whereby such X-ray, ultrasound, or radiographic imaging test shall be read and interpreted by a physician who is trained in the reading and interpretation of such tests; a report of such X-ray, ultrasound, or radiographic imaging test may be reviewed by the APRN; and a copy of such report shall be forwarded to the delegating physician, except that such provision for an ultrasound shall not be required for an APRN acting within his or her scope of practice as authorized by Code Sections 43-26-3 and 43-26-5;
          • Require documentation either in writing or by electronic means or other medium by the APRN of those acts performed by the advanced practice registered nurse which are specific to the medical acts authorized by the delegating physician;
          • Include a schedule for periodic review by the delegating physician of patient records. Such patient records review may be achieved with a sampling of such records as determined by the delegating physician;
          • Provide for patient evaluation or follow-up examination by the delegating physician or other physician designated by the delegating physician pursuant to paragraph (2) of this subsection, with the frequency of such evaluation or follow-up examination based on the nature, extent, and scope of the delegated act or acts as determined by the delegating physician in accordance with paragraph (3) of this subsection and accepted standards of medical practice as determined by the board;
          • Be reviewed, revised, or updated annually by the delegating physician and the APRN;
          • Be available for review upon written request to the advanced practice registered nurse by the Georgia Board of Nursing or to the physician by the board; and
          • Provide that a patient who receives a prescription drug order for any controlled substance pursuant to a nurse protocol agreement shall be evaluated or examined by the delegating physician or other physician designated by the delegating physician pursuant to paragraph (2) of this subsection on at least a quarterly basis or at a more frequent interval as determined by the board.
      • Where must the agreement be stored?
        • Agreement must be kept at each practice site where the APRN is authorized to perform delegated acts.
      • Does the agreement need to be filed with the state?
        • Yes, if the APRN is prescribing as part of their practice. Nurse protocol agreement must be submitted within 30 days of execution to the Georgia Composite Medical Board. APRNs do NOT have prescriptive authority until approved by the Board.
      • Are there requirements to file the agreement after the initial filing?
        • A delegating physician shall notify the Board within ten (10) working days of the date of termination of a nurse protocol agreement with the delegating physician and APRN.
        • In the event of the death or departure of a delegating physician, an APRN must notify the Board within 7 days. If a designated physician is available according to an approved protocol agreement, he or she may serve as the delegating physician for up to 60 days (from the date of death of departure) until a new protocol agreement is approved by the Board. In the event that there is no designated physician, the APRN will not have prescriptive authority until a new signed protocol agreement is submitted to the Board.
      • Who must sign the agreement?
        • The delegating physician, other designated physician (if applicable), and the APRN.
      • How often must the agreement be reviewed/reauthorized?
        • The agreement must be reviewed annually.

      Qualifications and Collaboration Requirements

      • What are the qualifications for the collaborating provider?
        • Licensed in Georgia with a principal practice location within Georgia or within 50 miles of the location where the agreement is being utilized in the state. Must be in a comparable specialty area or field of the APRN.
      • What are the qualifications for the NP?
      • Is an alternate collaborating physician required?
        • Not required but permitted. The alternative is known as a "designated physician".
      • Are there ratios/limits on the number of NPs that a collaborator may supervise or enter into collaboration agreements?
        • There are some exemptions (see Medical Practice Act) that apply, but usually a delegating physician may not enter into a nurse protocol agreement with more than four (4) APRN’s at any one time.
        • The limitation shall not apply to an advanced practice registered nurse who is practicing:
          • In a hospital licensed under Title 31;
          • In any college or university as defined in Code Section 20-8-1;
          • In the Department of Public Health;
          • In any county board of health;
          • In any community service board;
          • In any free health clinic;
          • In a birthing center;
          • In any entity:
            • Which is exempt from federal taxes pursuant to Section 501(c)(3) of the Internal Revenue Code, as defined in Code Section 48-1-2, and primarily serves uninsured or indigent Medicaid and medicare patients; or
            • Which has been established under the authority of or is receiving funds pursuant to 42 U.S.C. Section 254b or 254c of the United States Public Health Service Act;
          • In any local board of education which has a school nurse program;
          • In a health maintenance organization that has an exclusive contract with a medical group practice and arranges for the provision of substantially all physician services to enrollees in health benefits of the health maintenance organization; or
          • In any emergency medical services system operated by, or on behalf of, any county, municipality, or hospital authority with a full-time physician medical director and who does not order drugs, except that he or she may order up to a 14 day supply of drugs as necessary in an emergency situation, excluding Schedule II controlled substances and benzodiazepines; provided, however, that an advanced practice registered nurse shall not order radiographic imaging, diagnostic studies, or medical devices pursuant to this paragraph; and provided, further, that a patient shall be referred to a physician, a dentist, or a federally qualified health center.
      • Is there an express requirement to review a certain number/percentage of charts?
        •  In as much as O.C.G.A. 43-34-25 requires that a delegating physician or other designated physician evaluate or examine all patients who receive any controlled substance prescription pursuant to a nurse protocol agreement, a delegating physician or other designated physician must review and sign 100% of patient records for patients receiving prescriptions for controlled substances to comply with the law. Such review shall occur at least quarterly after issuance of the controlled substance prescription.
        • The delegating physician or other designated physician reviews and signs 100% of patient records in which an adverse outcome has occurred. Such review shall occur no more than 30 days after the discovery of an adverse outcome.
        • The delegating physician or other designated physician reviews and signs 10% of all other patient records. Such review shall occur at least annually.
      • Is there a requirement to meet and if so, how often and how?
        • Location-specific requirements and agreement specifications.
      • Are there proximity requirements?
        • Physician’s principal place of practice must be within Georgia or within 50 miles from where the nurse protocol agreement is being used within Georgia.
      • Are there location-specific requirements?
        • Delegating physicians must document onsite observation and medical record review at least quarterly to monitor quality of care.
      • Is remote supervision allowed/are there limitations on remote supervision?
        • Remote supervision is permitted, but the delegating physician shall be available for immediate consultation with the advanced practice registered nurse. If the delegating physician is not available, the delegating physician for purposes of consultation may designate another physician who concurs with the terms of the nurse protocol agreement as provided in O.C.G.A. 43-34-25.

      Filing Requirements and Prescription Guidelines

      • Physician and NP filing requirements – outside of filing the collab agreement, must the physician and/or NP file any separate forms? (e.g., notice of delegation of prescriptive authority, notice of collaboration, notice to PDMP, etc.) NOTE: timing/frequency should be noted because the state may have requirements for initial filing and/or filing for updates, terminations, etc.
      • What are the prescription requirements?
        • A written prescription drug order shall be signed by the APRN and shall be on a form which shall include, without limitation, the names of the APRN and delegating physician who are parties to the nurse protocol agreement, the patient’s name and address, the drug or device ordered, directions with regard to the taking and dosage of the drug or use of the device, and the number of refills. A prescription drug order which is transmitted either electronically or via facsimile shall conform to the requirements set out in paragraphs (1) and (2) of subsection (c) of Code Section 26-4-80, respectively.
        • With prescriptive authority, an APRN writes and signs his/her own prescriptions. No co signatures are required.
      • What are the requirements for controlled substance prescribing?
        •  Delegating physician or designated physician must evaluate/examine every patient for whom Nurse Practitioner prescribes controlled substances at least quarterly.

      Sources for Reference

      State Regulations for Physician Assistants

      Limitation on Number of PAs Supervised
      • No primary supervising physician shall enter into a job description with or supervise more than four physician assistants at a time. O.C.G.A. § 43-34-103(b)(1). Ga. Comp. R. & Regs. r. 360-5-.05(4).There are exceptions for hospitals, college or university, government health, birthing centers, and free clinics. The limit is 8 for PAs who have completed a board approved anesthesiologist assistant program. A physician may be an alternate supervising physician for any number of PA. When acting as a Primary or Alternate supervising physician, a physician may supervise as many as four PAs at one time, who are working within the scope of practice of the Supervising Physician. Ga. Comp. R. & Regs. r. 360-5-.05.
      Review of PA Medical Records
      • The supervising physician shall periodically review patient records. Such review may be achieved with a sampling of such records as determined by the supervising physician. O.C.G.A § 43-34-103(e)(6)
      Prescribing
      • The PA shall only be authorized to prescribe using a prescription drug or device order form which includes the name, address, and telephone number of the prescribing supervising or alternate supervising physician, the patient’s name and address, the drug or device prescribed, the number of refills, and directions to the patient with regard to the taking and dosage of the drug. O.C.G.A. § 43-34-103(e)(3). A physician may delegate to a PA, in accordance with a job description, the authority to issue a prescription drug order or orders for any device or to issue any dangerous drug or any Schedule III, IV, or V controlled substance. O.C.G.A. § 43-34-103(e)(1); O.C.G.A. § 43-34-23. A supervising physician or alternate supervising physician shall evaluate or examine, at least every three months, any patient receiving controlled substances. O.C.G.A. § 43-34-103(e)(5).
      • The primary supervising physician shall at all times maintain on file, readily available for inspection, documentation from the Board evidencing current approval for supervision of the PA, current license status of both parties, and a copy of the applicable approved job description. Ga. Comp. R. & Regs. r. 360-5-.03(6).