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      Collaborating in New Jersey

      Review the requirements to collaborate in New Jersey

      State Regulations for Nurse Practitioners

      General

      • State Category: Collaboration Required for Prescriptive Authority

      Delegation Authority/Process

      • Is an agreement required?
        • Yes, an agreement, termed a "Joint Protocol," is required.
      • What form of agreement is required?
        • The content of a joint protocol shall address:
          • 1. The nature of the practice, the patient population (for example, pediatric patients) and settings (for example, inpatient, nursing home, patient residences or other alternative care environments);
          • 2. Any particular circumstances for which, prior to prescribing, a specific examination is to be performed or a definitive diagnosis made;
          • 3. The recordkeeping methodology to be used in the practice (for example, the protocol might indicate that records should contain subjective complaints, objective findings, an assessment and a plan of treatment);
          • 4. A list of categories of medications appropriate to the practice;
          • 5. A delineation of specific medications and the specific number of refills, to be prescribed pursuant to the direction of the physician;
          • 6. Specific requirements with respect to the recordation, in the patient record and/or in separate logs, of medications prescribed or dispensed, dosages, frequency, duration, instructions for use and authorizations for refills;
          • 7. Any medical conditions or findings within the nature of the practice which should require direct consultation prior to the prescribing or ordering of medications or devices;
          • 8. The frequency and methodology to be employed to ensure periodic review of patient records;
          • 9. Identification of the means by which the APRN and collaborating physician can be in direct communication, as well as a description of arrangements which will assure that the collaborating physician or peer coverage is accessible and available;
          • 10. Procedures for the use of medications in emergency situations; and
          • 11. Identification of reference materials containing practice guidelines or accepted standards of practice.
      • Where must the agreement be stored?
        • Agreement must be maintained on-site in every office where the APRN practices.
      • Does the agreement need to be filed with the state?
        • No explicit requirement.
      • Are there requirements to file the agreement after the initial filing?
        • No requirement
      • Who must sign the agreement?
        • Both the APRN and collaborating physician.
      • How often must the agreement be reviewed/reauthorized?
        • The agreement must be updated on an ongoing basis to reflect changes in the practice, office personnel, skills of the APRN, frequency of record review, and reference materials containing practice guidelines or accepted standards of practice and reviewed at least on an annual basis.
      • What are the qualifications for the collaborating provider?
        •  Physician, no other requirements identified.  
      • What are the qualifications for the NP?
      • Is an alternate collaborating physician required?
        • No explicit requirement.

      Collaboration Requirements

      • Are there ratios/limits on the number of NPs that a collaborator may supervise?
        • No explicit requirement.
      • Is there an express requirement to review a certain number/percentage of charts?
        • Charts and patient records must be periodically reviewed by the collaborating physician and APRN, but no frequency is defined.
      • Is there a requirement to meet and, if so, how often and how?
        • No explicit requirement.
      • Are there proximity requirements?
        • No specific requirement.
      • Are there location-specific requirements?
        • No requirement.
      • Is remote supervision allowed/are there limitations on remote supervision?
        • Remote supervision not prohibited. The physician must be present or readily available through electronic communications in order for a NP to order medications.
      • Physician and NP filing requirements
        • No additional filing requirements beyond the Joint Protocol.
      • What are the prescription requirements?
        • An advanced practice nurse shall include the following information on each prescription blank issued:
          • 1. The prescribing advanced practice nurse's full name, designation, that is, APN, address, telephone number, and certification number;
          • 2. The full name, date of birth and address of the patient;
          • 3. The date of issuance;
          • 4. The name, strength, route and quantity of the medication prescribed;
          • 5. The number of refills permitted or time limit for refills, or both;
          • 6. A handwritten, original signature;
          • 7. An explicit indication, by initials placed next to "do not substitute," if a specified brand name drug is to be dispensed;
          • 8. The full name, title, address, telephone number, and license number of the collaborating physician;
          • 9. Words, in addition to numbers, to indicate the drug quantity authorized if the prescription is for a controlled dangerous substance, for example: "ten (10) Percodan" or "five (5) Ritalin 5 mg"; and
          • 10. If the prescription is for a controlled dangerous substance, the advanced practice nurse's DEA number and instructions as to the frequency of use.
        • An APRN who prescribes medication or devices shall advise patients by a sign or pamphlets in the waiting room of the office, that a patient may request a generic drug as a substitute for a brand name drug prescribed.
        • Each prescription for a controlled dangerous substance shall be written on a separate New Jersey Prescription Blank.
        • An APRN may prescribe medications and devices in all other medically appropriate settings, subject to the following conditions:
          • (1) the collaborating physician and advanced practice nurse shall address in the joint protocols whether prior consultation with the collaborating physician is required to initiate a prescription for a controlled dangerous substance;
          • (2) the prescription is written in accordance with standing orders or joint protocols developed in agreement between a collaborating physician and the APRN, or pursuant to the specific direction of a physician;
          • (3) the APRN writes the prescription on a New Jersey Prescription Blank pursuant to P.L.2003, c.280 (C.45:14-40 et seq.), signs the nurse’s own name to the prescription and prints the nurse’s name and certification number;
          • (4) the prescription is dated and includes the name of the patient and the name, address, and telephone number of the collaborating physician;
          • (5) the physician is present or readily available through electronic communications;
          • (6) the charts and records of the patients treated by the advanced practice nurse are periodically reviewed by the collaborating physician and the APRN;
          • (7) the joint protocols developed by the collaborating physician and the APRN are reviewed, updated, and signed at least annually by both parties; and
          • (8) the APRN has completed six contact hours of continuing professional education in pharmacology related to controlled substances, including pharmacologic therapy, addiction prevention and management, and issues concerning prescription opioid drugs, including responsible prescribing practices, alternatives to opioids for managing and treating pain, and the risks and signs of opioid abuse, addiction, and diversion, in accordance with regulations adopted by the New Jersey Board of Nursing. The six contact hours shall be in addition to New Jersey Board of Nursing pharmacology education requirements for advanced practice nurses related to initial certification and recertification of an APRN as set forth in N.J.A.C.13:37-7.2.
        • An APRN may authorize qualifying patients for the medical use of cannabis and issue written instructions for medical cannabis to registered qualifying patients, subject to the following conditions:
          • (1) the collaborating physician and APRN shall address in the joint protocols whether prior consultation with the collaborating physician is required to authorize a qualifying patient for the medical use of cannabis or issue written instructions for medical cannabis;
          • (2) the authorization for the medical use of cannabis or issuance of written instructions for cannabis is in accordance with standing orders or joint protocols developed in agreement between a collaborating physician and the APRN, or pursuant to the specific direction of a physician;
          • (3) the APRN signs the APRN’s own name to the authorization or written instruction and prints the nurse’s name and certification number;
          • (4) the authorization or written instruction is dated and includes the name of the qualifying patient and the name, address, and telephone number of the collaborating physician;
          • (5) the physician is present or readily available through electronic communications;
          • (6) the charts and records of qualifying patients treated by the APRN are periodically reviewed by the collaborating physician and the APRN;
          • (7) the joint protocols developed by the collaborating physician and the APRN are reviewed, updated, and signed at least annually by both parties; and
          • (8) the APRN complies with the requirements for authorizing qualifying patients for the medical use of cannabis and for issuing written instructions for medical cannabis established pursuant to P.L.2009, c.307 (C.24:6I-1 et al.).
        • Inpatient prescribing requirements are set forth in N.J. Stat. § 45:11-49.
      • What are the requirements for controlled substance prescribing?
        • See N.J.A.C. 13:37-7.9A.
        • When prescribing, dispensing, or administering controlled dangerous substances, an APRN shall:
          • 1. Take a thorough medical history of the patient which reflects the nature, frequency, and severity of any pain, the patient's history of substance use or abuse, and the patient's experience with non-opioid medication and non-pharmacological pain management approaches;
          • 2. Conduct a physical examination, including an assessment of physical and psychological function, and an evaluation of underlying or coexisting diseases or conditions;
          • 3. Access relevant prescription monitoring information as maintained by the Prescription Monitoring Program (PMP) pursuant to N.J.S.A. 45:1-46.1 and consider that information in accordance with N.J.A.C. 13:45A-35;
          • 4. Develop a treatment plan, which identifies the objectives by which treatment success is to be evaluated, such as pain relief and improved physical and psychological function, and any further diagnostic evaluations or other treatments planned, with particular attention focused on determining the cause of the patient's pain; and
          • 5. Prepare a patient record that reflects the medical history, the findings on examination, any relevant PMP data, and the treatment plan, as well as:
            • i. The complete name of the controlled substance;
            • ii. The dosage, strength, and quantity of the controlled substance; and
            • iii. The instructions as to frequency of use.
        • With respect to Schedule II controlled dangerous substances, unless the prescribing of opioids is subject to limitations as set forth below, an APRN may authorize a quantity, not to exceed a 30-day supply, which shall be at the lowest effective dose as determined by the directed dosage and frequency of dosage.
        • Prior to issuing an initial prescription for a Schedule II controlled dangerous substance or any opioid drug in the course of treatment for acute pain, an APRN shall discuss with the patient, or the patient's parent or guardian if the patient is under 18 years of age and is not an emancipated minor, the reasons why the medication is being prescribed, the possible alternative treatments, and the risks associated with the medication. With respect to opioid drugs, the discussion shall include, but not be limited to, the risks of addiction, including that opioids are highly addictive, even when taken as prescribed and used as directed, physical or psychological dependence, and overdose associated with opioid drugs and the danger of taking opioid drugs with alcohol, benzodiazepines, and other central nervous system depressants, and requirements for proper storage and disposal.
          • 1. If the patient is under 18 years of age and is not an emancipated minor, the APRN shall have the discussion required above prior to the issuance of each subsequent prescription for any opioid drug that is a Schedule II controlled dangerous substance.
          • 2. The APRN shall reiterate the discussion required above prior to issuing a prescription at the outset of a course of treatment for chronic pain for a Schedule II controlled dangerous substance or any opioid drug.
          • 3. The APRN shall include a note in the patient record that the required discussion(s) took place.
        • Prior to the commencement of an ongoing course of treatment for chronic pain with a Schedule II controlled dangerous substance or any opioid, the APRN shall enter into a pain management agreement with the patient. The pain management agreement shall be a written contract or agreement that is executed between an APRN and a patient, that is signed and dated prior to the commencement of an ongoing course of treatment for chronic pain using a Schedule II controlled dangerous substance or any opioid drug, and which shall:
          • 1. Document the understanding of both the APRN and the patient regarding the patient's pain management plan;
          • 2. Establish the patient's rights in association with treatment, and the patient's obligations in relation to the responsible use, discontinuation of use, and storage and disposal of Schedule II controlled dangerous substances and any opioid drugs, including any restrictions on the refill or acceptance of such prescriptions from APRNs and other prescribers;
          • 3. Identify the specific medications and other modes of treatment, including physical therapy or exercise, relaxation, or psychological counseling, that are included as part of the treatment plan;
          • 4. Specify the measures the APRN may employ to monitor the patient's compliance including, but not limited to, random specimen screens and pill counts; and
          • 5. Delineate the process for terminating the agreement, including the consequences if the APRN has reason to believe that the patient is not complying with the terms of the agreement.
        • When controlled dangerous substances are continuously prescribed for management of chronic pain, the APRN shall:
          • 1. Review, at a minimum of every 3 months, the course of treatment, any new information about the etiology of the pain and the patient's progress toward treatment objectives, and document the results of that review;
          • 2. Assess the patient prior to issuing each prescription to determine whether the patient is experiencing problems associated with physical and psychological dependence, and document the results of that assessment;
          • 3. Make periodic reasonable efforts, unless clinically contraindicated, to either stop the use of the controlled dangerous substance, taper the dosage, try other drugs such as nonsteroidal anti-inflammatories, or utilize alternative treatment modalities in an effort to reduce the potential for abuse or the development of physical or psychological dependence, and document, with specificity, the efforts undertaken;
          • 4. Access relevant prescription monitoring information as maintained by the Prescription Monitoring Program (PMP) pursuant to N.J.S.A. 45:1-46.1 and consider that information in accordance with N.J.A.C. 13:45A-35;
          • 5. Monitor compliance with the pain management agreement and any recommendations that the patient seek a referral, and discuss with the patient any breaches that reflect that the patient is not taking the drugs prescribed or is taking drugs, illicit or prescribed by other APRNs or prescribers, and document within the patient record the plan after that discussion;
          • 6. Conduct random urine screens at least once every 12 months;
          • 7. Advise the patient, or the patient's parent or guardian if the patient is under 18 years of age and is not an emancipated minor, of the availability of an opioid antidote; and
          • 8. Refer the patient to a pain management or addiction specialist for independent evaluation or treatment in order to achieve treatment objectives, if those objectives are not being met.
        • An APRN shall not issue an initial prescription for an opioid drug for treatment of acute pain in a quantity exceeding a 5-day supply as determined by the directed dosage and frequency of dosage. The initial prescription shall be for the lowest effective dose of an immediate-release opioid drug. An APRN shall not issue an initial prescription for an opioid drug that is for an extended-release or long-acting opioid. No less than 4 days after issuing the initial prescription, upon request of the patient, an APRN may issue a subsequent prescription for an opioid drug for the continued treatment of acute pain associated with the condition that necessitated the initial prescription provided the following conditions are met:
          • 1. The APRN consults (in person, via telephone, or other means of direct communication) with the patient;
          • 2. After the consultation with the patient, the APRN, in the exercise of his or her professional judgment, determines that an additional days' supply of the prescribed opioid drug is necessary and appropriate to the patient's treatment needs and does not present an undue risk of abuse, addiction, or diversion;
          • 3. The APRN documents the rationale for the authorization in the patient record;
          • 4. The subsequent prescription for an additional days' supply of the prescribed opioid drug is tailored to the patient's expected need at the stage of recovery, as determined above and any subsequent prescription for an additional days' supply shall not exceed a 30-day supply.
        • When an APRN issues an initial prescription for an opioid drug for the treatment of acute pain, the practitioner shall indicate it on the prescription.
        • When an APRN issues a prescription for an opioid drug that is a controlled dangerous substance to a patient, the APRN shall also issue the patient a prescription for an opioid antidote when the patient has a history of substance use disorders, the prescription for the opioid drug is for a daily dose of more than 90 morphine milligram equivalents, or the patient holds a current, valid prescription for a benzodiazepine drug that is a Schedule III or Schedule IV controlled dangerous substance.
          • 1. An APRN shall not be required to issue more than one prescription for an opioid antidote to a patient per year.
          • 2. Nothing above shall be construed to prohibit an APRN from issuing additional prescriptions for an opioid antidote to a patient upon the patient's request or when the APRN determines there is a clinical or practical need for the additional prescription.

      Sources for Reference