GA R&R - GAC (2024)

Rule 360-32-.01 Definitions

As used in this Chapter the term

Rule 360-32-.02 Requirements for Nurse Protocol Agreements Pursuant to Code Section 43-34-25

A physician entering into a nurse protocol agreement with an APRN pursuant to Code Section 43-34-25 shall include the following general data in the protocol agreement:

(a)	Names, addresses, telephone numbers, license numbers, and DEA registration number for all parties to the nurse protocol agreement, including any other designated physicians that will be utilized if the delegating physician is not available;

(b)	The delegating physician must provide the APRN's DEA number to the Board within 30 days of issuance.

(c)	Description of practice and number of locations, including primary and proposed satellite site(s);

(d)	Dates of initiation and amendments. Any amendments made to the protocol agreement shall be filed with the Board for review within 30 days of execution; and

(e)	Information regarding the specialty area or field of the APRN.

(2)	The agreement shall contain a provision for immediate consultation, as defined in Rule 360-32-.01, between the APRN and the delegating physician.

(3)

If the delegating physician is not available for consultation, the delegating physician may designate another physician who concurs with the terms of the nurse protocol agreement. The designation of another physician must also meet the following terms:

(a)	Such designation by the delegating physician shall be in writing and attached to the nurse protocol agreement;

(b)	Such designation must be to a physician whose scope of practice is the same as that of the delegating physician; and

(c)

Such designation must include the printed name, license number and signature of the other designated physician with an affirmation from the other designated physician that he or she has agreed to serve as an, other designated physician, has reviewed the nurse protocol agreement and concurs with the terms of the agreement.

(4)	The nurse protocol agreement shall outline and identify the applicable standard of care and shall be specific to the patient population seen.

(5)

The nurse protocol agreement shall identify the parameters under which the delegated act may be performed by the APRN, including but not limited to:

(a)	Drugs, devices, medical treatments, diagnostic studies that may be ordered and implemented by the APRN.

(b)	Circ*mstances under which a prescription drug order or device may be executed;

(c)

Number of refills which may be ordered. Nothing in this Rule shall be construed to authorize an advanced practice registered nurse to issue a prescription drug order for a Schedule I or II controlled substance or authorize refills of any drug for more than 12 months from the date of the original order except in the case of oral contraceptives, hormone replacement therapy, or prenatal vitamins which may be refilled for a period of 24 months as provided in O.C.G.A. 43-34-25.

(d)

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 as provided in O.C.G.A. 43-34-25 on at least a quarterly basis or at a more frequent interval as consistent with the minimum acceptable standards of the practice of medicine as determined by the Board.

(e)	Extent to which medical imaging may be ordered;

(f)	A predetermined plan for emergency services;

(g)

If the delegating physician authorizes the APRN to order an X-ray, ultrasound or medical imaging, the nurse protocol agreement shall contain provisions whereby such tests shall be read and interpreted by a physician who is trained in reading and interpretation of such tests and provide that a copy of such report shall be forwarded to the delegating physician. However, 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. Orders for medical imaging should include the indication for testing as well as the name, address, and telephone number of the delegating physician;

(h)	A section that details specific patient conditions and circ*mstances that require direct, on-site evaluation or consultation by the delegating physician; and

(i)	If the protocol agreement delegates to the APRN to prescribe/order prescription drugs, then a section that specifically provides that such delegation does not include the to prescribe/order prescription drugs intended to cause an abortion to occur pharmacologically.

(j)	A physician may delegate to an advanced practice registered nurse in accordance with a nurse protocol agreement the authority to pronounce death and to certify such pronouncement in the same manner as a physician.

(6)

The nurse protocol agreement shall require documentation by the APRN of those acts performed by the APRN that are specific to the medical acts authorized by the delegating physician and provide that, if the APRN has prescribing pursuant to the protocol agreement, each prescription shall be noted in the patient's medical record.

(a)

If the protocol agreement delegates to the APRN to prescribe/order prescription drugs or devices, a copy of the prescription drug or device order delivered to the patient shall be maintained in the patient's medical file. For purposes of this paragraph a copy shall mean a duplicate prescription or a photocopy or electronic equivalent.

(b)

If the protocol agreement delegates to the APRN to prescribe/order prescription drugs or devices, the protocol shall provide that the prescription/order shall be issued on a form which contains the following:

The name, address and telephone number of the delegating physician, the name of the APRN, the APRN's DEA number, if applicable, and the name and address of the patient, the drug or device prescribed, the number of refills and directions to the patient with regard to taking and dosage of the drug; and

2.	The prescription shall be signed by the APRN and shall be on a form which shall include the names of the APRN and delegating physician who are parties to the nurse protocol agreement.

(7)

(a)

Unless the physician meets the requirements of paragraph (b), the nurse protocol agreement shall include a schedule for periodic review of patient records. The Board has determined that the minimum accepted standards of medical practice require the following:

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.

2.	The delegating physician or other designated physician review and sign 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.

3.	The delegating physician or other designated physician review and sign 10% of all other patient records. Such review shall occur at least annually.

(b)

Pursuant to O.C.G.A. Section 43-34-25(g.1), a physician at a location that maintains evidence-based clinical practice guidelines and is accredited by an accrediting body approved by the Board such as Joint Commission may enter into a nurse protocol agreement with not more than eight advanced registered nurses at any one time and supervise not more than four advanced registered nurses. At those locations, such protocol must include the following:

1.	The delegating physician must document and maintain a record of review of at least 10 percent of the advanced practice registered nurses' medical records to monitor the quality of care being provided to patients, which may be conducted electronically or onsite;

2.	The delegating physician and the advanced practice registered nurse must participate in and maintain documentation of quarterly clinical collaboration meetings, either by telephone, in person, or onsite, for the purposes of monitoring care being provided to patients, and

3.	The delegating physician's name, contact information, and record of the visit must be provided to the patient's primary care provider of choice with the patient's consent within 24 hours of the visit.

(8)

The nurse protocol agreement shall indicate whether the APRN is authorized under the nurse protocol agreement to request, receive, sign for and distribute professional samples.

(a)

If the nurse protocol agreement provides this, the APRN shall comply with O.C.G.A. 43-34-25 which states: An advanced practice registered nurse may be authorized under a nurse protocol agreement to request, receive, and sign for professional samples and may distribute professional samples to patients. The office or facility at which the advanced practice registered nurse is working shall maintain a list of the professional samples approved by the delegating physician for request, receipt, and distribution by the advanced practice registered nurse as well as a complete list of the specific number and dosage of each professional sample and medication voucher received and dispensed. In addition to the requirements of this Code section, all professional samples shall be maintained as required by applicable state and federal laws and regulations.

(9)	Copies of the nurse protocol agreement shall be available at each practice site where the APRN is authorized to perform the delegated acts and shall be made available upon written request by the Board to the physician at the appropriate practice site.

(10)	The nurse protocol agreement shall be dated and signed by the delegating physician, other designated physician, if applicable, and the APRN.

(11)	A nurse protocol agreement between a physician and an advanced practice registered nurse shall be reviewed, revised, or updated annually by the delegating physician and the advanced practice registered nurse.

Rule 360-32-.03 Filing of Nurse Protocol Agreement with the Board

(1)	The delegating physician shall file the nurse protocol agreement and a Board approved form with the Board for review and submits the requisite fee for review established in the Board's fee schedule. Fees are non-refundable.

(2)

In addition to submitting the nurse protocol agreement to the Board for review, the delegating physician shall obtain from the APRN and submit to the Board current verification from the Georgia Board of Nursing that the APRN is approved to practice as an APRN and whether the APRN has had any disciplinary action taken against him or her by the Georgia Board of Nursing.

(3)	If, after review, the Board determines that the nurse protocol agreement fails to meet accepted standards of medical practice, the delegating physician will be so notified and be required to amend the agreement in order to comply with such accepted standards.

(4)	The delegating physician shall file with the Board amendments to nurse protocol agreements previously reviewed by the Board within 30 days of the date the amendment was executed.

(5)	Nurse protocol agreements must be received by the Board within 30 days from the date of execution of the agreement.

(6)	Incomplete protocols that have been on file with the Board for more than three months shall be deemed invalid. No further action will take place on the protocol requests that have been incomplete for more than three months and a new protocol and fee will be required.

Rule 360-32-.04 Limitations

(1)	A physician whose medical license is restricted shall not enter into a nurse protocol agreement, unless the physician has received prior written approval from the Board.

(2)	No physician shall delegate to an individual pursuant to the provisions of Code Section 43-34-25, unless the individual is fully approved by the Georgia Board of Nursing to practice as an APRN.

(3)	No physician may enter into a nurse protocol agreement with an APRN whose specialty area or field is not comparable to the physician's specialty area or field.

(4)

Unless specifically exempted by paragraphs (g), (g.1), or (g.2) of Code Section 43-34-25, a delegating physician may not enter into a nurse protocol agreement with more than four APRN's at any one time. A delegating physician meeting the provisions of Code section 43-34-25(g.1) or (g.2) may enter into a nurse protocol agreement not with more than eight APRN's at any one time, but may only supervise up to four APRN's at any one time.

(5)	Except for practice settings identified in paragraph (7) of subsection (g) of Code Section 43-34-25, a physician shall not be an employee of an APRN, alone or in combination with others, if the physician delegates to and/or is required to supervise the employing APRN.

(6)

No delegating physician shall delegate to an APRN the ability to prescribe controlled substances for the delegating physician, for the members of the delegating physician's immediate family, for the APRN himself or herself, or for the APRN's immediate family. For purposes of this rule,"immediate family" shall include spouses, children, siblings and parents.

Rule 360-32-.05 Additional Requirements Regarding Physician Delegation to an APRN

(1)

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.

(2)

The delegating physician shall document and maintain a record of direct onsite observation of the practice of the APRN, conducted at least once annually, except for physicians with protocols that qualify under O.C.G.A. § 43-34-25(g.1). Additionally, the delegating physician shall conduct a review of medical records on a quarterly basis; this review may be conducted via telecommunications to monitor quality of care being provided to the patients.

(3)

The delegating physician shall make certain that the medical acts provided by the APRN pursuant to the protocol agreement are:

(a)

Commensurate with the education, training, experience, and competence of the APRN:

A delegating physician shall therefore ensure that an APRN to whom he delegates prescriptive receives pharmacology training appropriate to the delegating physician's scope of practice at least annually. Documentation of such training shall be maintained by the physician and provided to the Board upon request.

2.	A delegating physician who fails to comply with subparagraph (3)(a)1. of this rule by delegating prescriptive to an APRN who has not received pharmacology training appropriate to the delegating physician's scope of practice at least annually may be subject to disciplinary action.

(b)	Within the scope of practice, specialty area or field and certification of the APRN;

(c)	Within the comparable specialty area or field of the delegating physician; and

(d)	Well documented in accurately maintained patient specific medical records.

(4)	The delegating physician is responsible for all the medical acts performed by the APRN.

(5)	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.

(6)

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 or 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.

(7)

The Board may request at any time to review the nurse protocol agreement and any supporting documentation. Failure to provide this written information to the Board within 30 days shall be a basis for and may result in disciplinary action. The Board may require changes in these documents if the Board determines that they do not comply with O.C.G.A. 43-34-25 and/or accepted standards of medical practice.

Rule 360-32-.06 Non-compliance

A delegating or other designated physician may be disciplinedfor failure to comply with this Chapter.

Rule 360-32-.07 Exemptions

Nothing in this rule shall be construed to require a physicianto delegate prescriptive or prohibit a physician from utilizing the protocolgranted under O.C.G.A. § 43-34-23.