Collaborating in Ohio

Review the requirements for collaborating in Ohio.

State Regulations for Nurse Practitioners

Delegation authority/process:

• Is an agreement required?

• • A “written Standard Care Agreement” is required.

• What form of agreement is required and what are the requirements for the substance of the agreement (is use of state template required?)

• • The written Standard Care Agreement must include:

• • • Criteria for the NP to refer patients to the collaborating physician;
    • A process for the NP to obtain a consultation with collaborating physician; 
    • A plan for coverage;
    • A plan for emergency care;
    • A plan for incorporation of new technology or procedures consistent with the applicable scope of practice;
    • The process for resolution of disagreements between the NP and collaborating physician regarding matters of patient management;
    • Signatures, specialty areas, phone numbers, and addresses of each NP and collaborating physician;
    • Date of initial execution and most recent review;
    • A statement of services offered by the NP, including a description of the scope of prescriptive practice;
    • Quality assurance provisions regarding chart review, including an opportunity for the collaborating physician and NP to discuss feedback or issues subsequent to each chart review, and a process for patient evaluation care; and
    • Quality assurance provisions regarding the prescribing component of the NP’s practice.

• • • Where must the agreement be stored?

• A copy of the standard care arrangement shall be retained on file by the nurse’s employer.
  • Copies of previously effective Standard Care Agreements must be maintained by the NP for three (3) years and provided to the Ohio Board of Nursing upon request.

• Does the agreement need to be filed with the state?

• • Prior approval of the standard care arrangement by the Ohio Board of Nursing is not required, but the board may periodically review it for compliance with this section.

• Are there requirements to file the agreement after the initial filing (e.g., for updates or on a specified frequency)

• • Not later than thirty days after first engaging in the practice of nursing as a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner, the APRN shall submit to the board the name and business address of each collaborating physician or podiatrist. Thereafter, the APRN shall notify the Ohio Board of Nursing of any additions or deletions to the APRN’s collaborating physicians or podiatrists.

• Who must sign the agreement?

• • The signatures of each APRN, and each collaborating physician, or the physician’s designated representative, or each podiatrist with whom the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist primarily collaborates indicate review of and agreement to abide by the terms of the standard care arrangement. For purposes of this rule, a physician’s designated representative means a physician who serves as the department or unit director or chair, within the same institution, organization or facility department or unit, and within the same practice specialty, that the nurse practices, and with respect to whom the physician has executed a legal authorization to enter collaborating agreements on the physician’s behalf.

• How often must the agreement be reviewed/reauthorized?

• • The Standard Care Agreement must be revised to reflect the addition or deletion of a collaborating physician. A new Standard Care Agreement is not necessary.
  • A new Standard Care Agreement must be entered into when the NP is employed at a different or additional organization or practice and engages in practice with a different collaborating physician outside of the primary employing organization.

•  What are the qualifications for the collaborating provider (licensure, same scope, active practice in state, etc.)?

• • Licensed to practice in Ohio.
  • The physician or podiatrist must be practicing in a specialty that is the same as or similar to the APRN’s nursing specialty. If the nurse is a clinical nurse specialist who is certified as a psychiatric-mental health CNS by the American nurses credentialing center or a certified nurse practitioner who is certified as a psychiatric-mental health NP by the American nurses credentialing center, the nurse may enter into a standard care arrangement with a physician but not a podiatrist and the collaborating physician must be practicing in one of the following specialties:

• • • (i) Psychiatry;
    • (ii) Pediatrics;
    • (iii) Primary care or family practice.

• What are the qualifications for the NP?
  • See here.

• Is an alternate collaborating physician required?

• • No requirement.

Collaboration requirements:

• Are there ratios/limits on the number of NPs that a collaborator may supervise or enter into collaboration agreements?

• • The collaborating physician may not supervise more than five (5) NPs in “the prescribing component of their practices.”

• Is there an express requirement to review a certain number/percentage of charts?

• • No required audit percentage; however, “periodic random chart review” must be performed at least annually.

• Is there a requirement to meet and, if so, how often and how?

• • No requirement.

• Are there proximity requirements? (e.g., between the NP/collaborator or practice site)

• • No requirement.

• Are there location-specific requirements? (e.g., that collaborator must go to practice site at some frequency)

• • No requirement.

• Is remote supervision allowed/are there limitations on remote supervision?

• • Remote supervision is permitted, provided the supervising physician is “continuously available” to communicate with the NP, either in person or by electronic communication.

• 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.

• • The NP must notify the Ohio Board of Nursing regarding the name and business address of each collaborating physician within thirty (30) days of commencing the Agreement.
  • The NP must also notify the Ohio Board of Nursing of any additions or deletions to the NP’s collaborating physicians within thirty (30) days of the change(s) taking effect.
  • If the collaborating physician provides the NP written/electronic notice of termination of the collaboration, the NP must notify the Ohio Board of Nursing as soon as practicable once the NP receives such notice. The NP must submit to the Board a copy of the collaborating physician’s termination note.
  • In the event the collaboration terminates because of the collaborating physician’s death, the NP must notify the Ohio Board of Nursing of the death as soon as practicable.

• What are the prescription requirements? (identifying collaborators on rxs, restrictions on certain categories of drugs that may or may not be scheduled [one area of concern right now is abortion-inducing medications], etc.)

• • The prescriptive authority of an advanced practice registered nurse designated as a certified nurse practitioner, clinical nurse specialist and certified nurse midwife shall not exceed the prescriptive authority of the collaborating physician or podiatrist.

• • A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may prescribe or personally furnish a drug according to section 4723.4810 of the Revised Code to not more than a total of two individuals who are sexual partners of the advanced practice registered nurse’s patient.

• What are the requirements for controlled substance prescribing?

• • Regarding the prescribing component of the clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner’s practice, the following quality assurance provisions shall include at least:

• • • (a) Provisions to ensure timely direct, personal evaluation of the patient with a collaborating physician or the physician’s designee when indicated;
    • (b) Prescribing parameters for drugs or therapeutic devices when indicated;
    • (c) Provisions for the use of schedule II controlled substances;
    • (d) If the nurse is prescribing to minors, as defined in division (A) of section 3719.061 of the Revised Code, provisions for complying with section 3719.061 of the Revised Code when prescribing an opioid analgesic to a minor; and
    • (e) Provisions for obtaining and reviewing OARRS reports, and engaging in physician consultation and patient care consistent with section 4723.487 of the Revised Code and rule 4723-9-12 of the Administrative Code.

• • For drugs that are a controlled substance:

• • • (a) The advanced practice registered nurse has obtained a United States drug enforcement administration registration, except if not required to do so as provided in rules adopted by agency 4729 of the Administrative Code, and indicates the number on the prescription;
    • (b) The prescription indicates the ICD-10-CM medical diagnosis code of the primary disease or condition that the controlled substance is being used to treat. The code shall, at minimum, include the first four alphanumeric characters of the ICD-10 CM medical diagnosis code, sometimes referred to as the category and etiology (ex. M165);
    • (c) The prescription indicates the days’ supply of the controlled substance prescription.
    • (d) The patient is not a family member; and
    • (e) The advanced practice registered nurse shall not self-prescribe a controlled substance.

• • • An advanced practice registered nurse with a current valid license issued by the board and designated as a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may prescribe a schedule II controlled substance only in situations where all of the following apply (certain exceptions apply when the APRN is working in a hospital/hospice/residential care facility):

• • • (1) A patient has a terminal condition;
    • (2) A physician initially prescribed the substance for the patient; and
    • (3) The prescription is for a quantity that does not exceed the amount necessary for the patient’s use in a single, seventy-two hour period.

• • • An advanced practice registered nurse designated as a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall not prescribe any drug or device to perform or induce an abortion.
    • Additional requirements for the prescribing for treatment of Acute Pain. See OAC § 4723-9-10.

Sources for Reference

• ORC Ann. 4723.431.
• OAC § 4723-8-04.
• OAC § 4723-8-05.
• OAC § 4723-9-10.