For NP’s in “Restricted” States, How Do Physician Chart Reviews and Sign-Offs Work?

Nurse practitioners are master's degree (MSN) or doctoral degree (DNP) nurses who have completed an NP program, specializing in a specific care population. Depending on the state in which they practice, they may be able to work independently, with a reduced practice, or with a restricted practice.

The difference between "reduced" and "restricted practice is the amount of oversight that is needed, as well as what an NP can or cannot do in their scope of practice. This is dictated by the state's board of registered nursing. The American Nurse Practitioner Association has a great deal of information regarding state-by-state NP scope of practice.

The specifics of NP oversight in restricted states vary. In California, for example, healthcare organizations must formulate and adopt a set of standardized procedures that nurse practitioners must follow. Specific guidelines are outlined by California's BRN. The standardized procedures must also "Specify the scope of supervision required for performance of standardized procedure functions, for example, immediate supervision by a physician." This means that the organization must be clear at how the NP is supervised. In other words, in California, the NP must practice in collaboration with a physician, but the organization specifies how the NP is supervised.

For example, the physician may perform chart reviews of nurse practitioners. Physicians may review the NP documentation to ensure the diagnosis and treatment of the patient are appropriate based on the physical exam. Sometimes there are written audit tools to make sure the critical elements of healthcare delivery are documented. Other times, the physician may shadow the NP during an exam to ensure the exam, diagnosis, and treatment is appropriate and aligned with current standards of care. The organization or insurance carrier determines how many charts/ exams are audited.

While NP oversight is mandatory in restricted states, the good news is the standardized procedures that specify the type of supervision is designed in collaboration with both physicians and nurse practitioners.

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Amanda Bucceri Androus, RN, BSN

Amanda Bucceri Androus is a Registered Nurse from Sacramento, California. She graduated from California State University, Sacramento in 2000 with a bachelor's degree in nursing. She began her career working night shifts on a pediatric/ med-surg unit for six years, later transferring to a telemetry unit where she worked for four more years. She currently works as a charge nurse in a busy outpatient primary care department. In her spare time she likes to read, travel, write, and spend time with her husband and two children.

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