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 and specialize in a specific care population. Depending on the state in which they practice, they may be able to work independently, with a reduced or restricted practice.
The difference between "reduced" and "restricted practice ” is the amount of oversight needed and 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 lot of information regarding the scope of practice of state-by-state NPs.
The specifics of NP oversight in restricted states vary. In California, for example, healthcare organizations must formulate and adopt standardized procedures that nurse practitioners must follow. California's BRN outlines specific guidelines. The standardized procedures must also "Specify the scope of supervision required for the performance of standardized procedure functions, for example, immediate supervision by a physician.” This means the organization must be clear about how the NP is supervised. In other words, in California, the NP must collaborate 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 ensure that 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 are 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 that the standardized procedures specifying the type of supervision are designed in collaboration with physicians and nurse practitioners.
