THE NURSE PRACTITIONER

SURVIVAL GUIDE

Updated *****

Updated 6/6/2023
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This guide can optimize your success in compliance with nurse practi-
tioner (NP) law and rules.

Always be prepared for an audit by having the following documenta-

tion in your NP notebook for up to the past 5 years:

• NATIONAL CERTIFICATION
IN ACCORDANCE WITH 21 NCAC 36 .0805 AND 21 NCAC 36 .0806 (A)(2) A NURSE
PRACTITIONER SHALL PROVIDE EVIDENCE OF CERTIFICATION OR RECERTIFICATION AS A
NURSE PRACTITIONER BY A NATIONAL CREDENTIALING BODY. CERTIFICATION MUST BE
MAINTAINED AT ALL TIMES.

• CONTINUING EDUCATION (CE)

• COLLABORATIVE PRACTICE AGREEMENT

(CPA)

• QUALITY IMPROVEMENT MEETINGS

(QI)

• CONTROLLED SUBSTANCES REPORTING

SYSTEM (CSRS)
ONLY IF PRESCRIBING CONTROLLED SUBSTANCES.

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CONTINUING Keep current and previous CE

EDUCATION documentation in

• NP Rule 21 NCAC 36.0807 states to maintain NP approval to practice,

the NP shall maintain national certification or earn 50 contact hours
MAINTAIN NATIONAL
of continuing education every two years. Your renewal will always be CERTIFICATION OR EARN
due on your birth month after the initial approval to practice has 50 CONTACT HOURS
been granted.
EVERY TWO YEARS.
Contact Hour
• At least 20 hours of the required 50 hours must be those hours for
INCLUDED AS A PART OF
which approval has been granted by the American Nurses Credential- THE TOTAL 50 CONTACT
ing Center (ANCC) or Accreditation Council on Continuing Medical Ed-
ucation (ACCME) or other national credentialing bodies or **practice
HOUR REQUIREMENT, 1
relevant courses in an institution of higher learning. The remaining CONTACT HOUR OF CE IS
30 hours must be CEs at the advanced practice level Included as a REQUIRED FOR THOSE
part of the total 50 contact hours (for those who have not maintained
national certification) 1 contact hour of CE is required for those NPs NPS WHO PRESCRIBE
who prescribe controlled substances. This CE shall address controlled CONTROLLED
substance prescribing practices, signs of the abuse or misuse of con-
trolled substances, and controlled substance prescribing for chronic
SUBSTANCES.
pain management.

**Note: By a national accredited provider of nursing continuing profes-

sional development, or nurse practice-relevant courses in an institution
CE DOCUMENTATION
of higher learning. A nurse practitioner who possesses a current national MUST PROVIDE YOUR
certification by a national credentialing body shall be deemed in compli- NAME AND NUMBER OF
ance with the requirement of Paragraph (a) of this Rule.
CONTACT HOURS
Only those courses completed during the two consecutive renewal cycles OBTAINED.
can be counted.
• The conversion for credit to contact hours are:
• 1 semester credit = 15 contact hours
• 1 quarter credit = 7.5 contact hours

For the activities below to count toward the CE requirement, they must
be completed every two consecutive years.

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 Activity Example Acceptable Evidence
Five (5) hours - Clinical Designing, developing and conducting an Dated copy of presentation(s)
Presentations educational presentation or presentations
for health professionals totaling a minimum Does not include poster presen-
of 5 contact hours tations.

Up to 30 Preceptor hours Precepting any Interprofessional Original letter from the program
healthcare student director stating the following:
1. Timeframe precepted
said student
2. Number of hours
precepted student

Five (5) hours - author on a • Professional journal article (both refer- Reference for published work
journal article or book chap- eed and non-refereed publications are copy of title page
ter published during renewal acceptable)
year • Published book chapter

Fifteen (15) hours - primary Author or Editor of published book Reference for published work
or secondary author of a copy of title page
book published during
renewal year

Ten (10) hours – Completion Completion of an IRB-approved research IRB close-out letter
of an Institutional Review project for which you were the primary
Board (IRB) approved re- Investigator.
search project related to
your certification specialty
Five (5) hours - Professional Local, state, national or international health Signed/dated attestation from
volunteer service care related organization in which your NP manager or committee chair
or certification specialty expertise is re-
quired. Examples:
• employer, community or profession-
specific board of director
• committees
• task forces
• editorial boards
• review boards

Initial or recertification in Basic Life Support (BLS) does not count toward NP continuing education credit.
Only initial certification in Advanced Cardiovascular Life Support (ACLS), Pediatric Advanced Life Support (PALS),
Neonatal Resuscitation Program (NRP) and instructor certification will count toward NP continuing education
credit if one has obtained a certificate with the date completed and number of contact hours provided.

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Anatomy of the Acceptable Contact Hour Certificate

ECC Example Certification Corporation The certificate must be approved by

the Nurses Credentialing Center
The Example Certification Corporation (ANCC) or Accreditation Council on
123 Nowhere Street, Suite 245 Continuing Medical Education
(ACCME), or other national creden-
LivingLarge, NY 12547 tialing bodies.

Certificate of Completion

Why Nurse Practitioners Are Awesome:

Must be a practice relevant contact
NPs and the Clinical Setting hour course.

JANE DOE, MSN, FNP-BC, RN The NP must have his or her name
on the certificate.

has successfully completed the offering listed and

has been awarded 5 contact hours on 11/2/2015. Contact hours must be listed as well
as the date the course
was completed.

The certificate must be approved by the

Nurses Credentialing Center (ANCC) or
Accreditation Council on Continuing Medical The approval language would be
stated on the certificate.
Education (ACCME), or other national credentialing
bodies for a specific amount of contact hours
(in this case 5).

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 North Carolina Board of Nursing
NP Continuing Education Record Form
Name: __________________________________ You may use this form to record your relevant CE.
Record Form #: ______________________ Use as many of the forms as needed. The Board
may request documentation of entries and
Dates: _________________ to __________________ corresponding contact hour certificates.

CE Activity Practice-Relevant Date(s) Hour Value

If provided by an accredited sponsor (ANCC, AANP, NCC, Subject
PNCB, or ACCME, Category I, other national credential-
ing bodies, or practice relevant courses in an institution
of higher learning), enter sponsor’s name and location,
type/nature of activity.

Must total at least 50 hours every two years. Refer to the NP Rules 21 NCAC 36.0807.
NP Renewal Cycle (birth month to birth month) - Example: Birth month: June
NP Renewal Cycle for 2023-2025 for licensee with the birth month of June: July 1, 2023—June 30, 2025.
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COLLABORATIVE
PRACTICE Keep signed/dated initial and

AGREEMENT
NP RULE 21 NCAC 36 .0810
annually reviewed CPAs in
NP notebook!

• Is the current Collaborative Practice Agreement (CPA) document CPA MUST BE

signed and dated by the NP and the primary supervising physician?
REVIEWED, SIGNED, AND
• If you have been in this specific approval longer than 1 year, have you DATED BY NP AND PRI-
evidence of annual reviews of the CPA document? The evidence can MARY SUPERVISING
either be a signature sheet appended to the CPA signed and dated by
the NP and the primary supervising physician, or individual CPAs for
PHYSICIAN ANNUALLY
each year signed and dated as mentioned.

• Does your CPA describe how the NP and the primary supervising phy-
sician are continuously available to each other? CPA MUST INCLUDE
• Drugs
• Does your CPA include drugs, devices, medical treatments, tests, and
procedures that may be prescribed, ordered, and performed by the
• Devices
NP? • Medical treatments
• Tests
• Does your CPA include a predetermined plan for emergency services? • Procedures
• Pre-determined plan for
emergency services
• How the NP and primary
supervising physician are
continuously
available to each other

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 THE FOLLOWING IS ONLY AN EXAMPLE OF A CPA.
BY NO MEANS SHOULD THIS DOCUMENT BE USED AS IS.
YOU AND YOUR PRIMARY SUPERVISING PHYSICIAN MUST DESIGN A CPA SPECIFIC TO YOUR
EDUCATION, CERTIFICATION, AND PRACTICE.

EXAMPLE— Collaborative Practice Agreement

This is a collaborative practice agreement between ___________, RN, MSN, ANP-BC and
________________, MD.

I. Demographic Information Look for the words in red font! They

indicate the elements required in a CPA.
Name: _________________RN, MSN, ANP-BC • Drugs
N.C. NP Approval Number: ___________ • Devices
• Medical treatments
Primary Supervising Physician: ______________, MD • Tests
• Procedures
• Pre-determined plan for emergency
Office Practice Site: services
• How the NP and primary are
Setting continuously available to each other

The NP will function within the following facilities:

Scope of Practice
1. As a certified adult nurse practitioner (ANP-BC), _______________will provide acute care ser-
vices and chronic disease management to clients admitted under the care of ________, MD at
the above listed facilities.

2. Clients that the NP will see will range in age from 14-100.

3. The most common clinical problems noted at the LTC facilities include pneumonia, urinary
tract infections, depression, hypertension, and diabetes, etc. Management of clients will be han-
dled in the following manner: Upon admission to the LTC facility, a complete review of the medi-
cal record, including computerized documents from hospitalizations and discharge summaries,
will be performed. Admission orders will be verified and/or written, based on information provid-
ed within the dictated discharge summary from the referring service and/or information con-
tained within the medical record, in combination with the NP’s assessment of their ongoing med-
ical needs. Clarification of appropriate orders or documented history, if needed, will be obtained
from the referring service by telephone contact. Therapy regimens will be developed after initial
assessment by PT/OT.
NP/Primary Supervising Physician Availability
Continuation of CPA example
The NP and the supervising physician will:
1. Collaborate in regards to care of the clients under our care at the listed LTC facilities.
2. The NP will consult with her primary supervising physician and/or backup supervising physician in any situa-
tion in which she feels uncertain regarding management of any client problem or concern.
3. The primary supervising physician will evaluate care given by the NP by reviewing notes written by the NP
and reviewing client cases as needed.
4. Both parties will be continuously available to each other for consultation by direct communication or tele-
communication.
In the event the supervising physician is unavailable, these standards will apply to the backup supervising phy-
sician with whom the NP is working.

Look for the words in red font! They

Emergency Services indicate the elements required in a CPA.
• Drugs
If a client’s status deteriorates to a point where the offending problem can • Devices
not be safely managed within the LTC facility, the NP will proceed to arrange • Medical treatments
for the client to be transferred back to acute inpatient care. In the event of • Tests
cardiac or respiratory arrest, the NP will notify the primary supervising phy- • Procedures
• Pre-determined plan for
sician or backup supervising physician and adhere to the policy of the LTC
emergency services
facility. • How the NP and primary are
continuously available to each
other
Prescribing Authority
__________________, RN, MSN, ANP-BC will be authorized to prescribe drugs as follows:
Drugs that may be prescribed must be included in the protocols approved by the NP and primary supervising
physician.

21 NCAC 36 .0809 (b)(2) PRESCRIBING AUTHORITY

Controlled Substances (Schedules II, IIN, III, IIIN, IV, V) defined by the State and Federal Controlled Substanc-
es Acts may be procured, prescribed, or ordered as established in the collaborative practice agreement.
(A) the nurse practitioner has an assigned DEA number that is entered on each prescription for a
controlled substance;
(B) refills may be issued consistent with Controlled Substance laws and regulations; and
(C) the primary supervising physician(s) shall possess a schedule(s) of controlled substances equal to or
greater than the nurse practitioner's DEA registration.
The drug categories that may be prescribed/ordered include: hypo-
Continuation of CPA example
glycemics/insulin, antiseizure, antihypertensives, antihistamines,
antipsychotics, antidepressants, antibiotics.

Look for the words in red font! They

(The language below is used in this example as the NP prescribes con- indicate the elements required in a CPA.
trolled substances.) • Drugs
• Devices
Controlled Substances (Schedules II, IIN, III, IIIN, IV, V) defined by the • Medical treatments
State and Federal Controlled Substances Acts may be procured, pre- • Tests
scribed, or ordered as established in the collaborative practice agree- • Procedures
ment. • Pre-determined plan for
emergency services
(A) the nurse practitioner has an assigned DEA number that is en- • How the NP and primary are
tered on each prescription for a controlled substance; continuously available to each

(B) refills may be issued consistent with Controlled Substance laws and
regulations; and
(C) the primary supervising physician(s) shall possess a schedule(s) of controlled substances equal
to or greater than the nurse practitioner's DEA registration.

The devices that may be ordered/prescribed include: DVAC therapy, OT supplies (reacher, sock aide, shoe
horn)
The tests that may be ordered/prescribed include:
The medical treatments that may be ordered/prescribed include:
The procedures that may be ordered/prescribed include:

It is recognized that no collaborative practice agreement can effectively cover every clinical situation.
Therefore, the collaborative practice agreement is not intended to be a substitute for the exercise of pro-
fessional judgment by the NP. There are situations involving client care, both common and unusual that
require the individualized exercise of the NP’s clinical judgment.

Documentation Requirements
This collaborative practice agreement must be reviewed at least annually and acknowledged by a signed
dated sheet. This signed and dated CPA must be kept at the practice site.

Approval Statement
We, the undersigned, agree to the terms of this collaborative practice agreement as set forth in this
document.

Primary Supervising Physician Signature: ____________________________

Date: _________

Nurse Practitioner Signature: ______________________________________

Date: _________

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 BACK-UP SUPERVISING PHYSICIAN(S) FORM
(DO NOT SEND THIS FORM TO THE BOARDS)

As described in 21 NCAC 36 .0801 (2): "Back-up Supervising Physician" means a physician licensed by the
Medical Board who, by signing this agreement with the nurse practitioner, acknowledges they understand
and agree to provide supervision, collaboration, consultation, and evaluation of medical acts by the nurse
practitioner in accordance with the collaborative practice agreement when the primary supervising physician
is not available.

NAME OF NURSE PRACTITIONER: ___________________________________________

Keep a copy of this form on file at all practice sites for which it applies as part of the inspectable supervisory
arrangements statement described in Rule 21 NCAC 32M.0101(11) and 21 NCAC 36.801(11).

(1) _____________________________________________________________ _______________________

(Signature of Back-up Physician) (Date)

(2) ____________________________________________________________ _______________________

(Signature of Primary Supervising Physician) (Date)

(3) ___________________________________________________________ _______________________

(Signature of Nurse Practitioner) (Date)

(1) _____________________________________________________________ _______________________

(Signature of Back-up Physician) (Date)

(2) ____________________________________________________________ _______________________

(Signature of Primary Supervising Physician) (Date)

(3) ___________________________________________________________ _______________________

(Signature of Nurse Practitioner) (Date)

(1) _____________________________________________________________ _______________________

(Signature of Back-up Physician) (Date)

(2) ____________________________________________________________ _______________________

(Signature of Primary Supervising Physician) (Date)

(3) ___________________________________________________________ _______________________

(Signature of Nurse Practitioner) (Date)

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QUALITY
IMPROVEMENT Keep all signed/dated
QI Meetings in

MEETINGS
NP RULE 21 NCAC 36 .0810(4) & (5) WHEN YOU ADD OR
• Have you provided copies of your documented Quality Improvement (QI)
CHANGE PRIMARY
meetings between the NP and the supervising physician that are to be held SUPERVISING
every month for the first six months of your collaborative practice agree-
ment?
PHYSICIANS, YOU MUST
HOLD AND DOCUMENT
• Do your documented QI meetings address clinical problem(s) discussed; QI MEETINGS AS
progress toward improving outcomes; and recommendations, if any, for
changes to treatment?
FOLLOWS:
• Monthly for the first six
• Are these documented QI meetings signed and dated by those who attend- months
ed, the NP, and the primary supervising physician? • Every six months there-
after

QI MEETING
DOCUMENTATION MUST
INCLUDE:
• Discussion of clinical
problems (practice
relevant)
• Progress toward
outcomes
• Recommendations,
if any, for changes in
treatment
• Signatures/dates of NP
and primary supervising
physician

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 SAMPLE
NP QI MEETING FORM

QUALITY IMPROVEMENT PROCESS – DOCUMENTATION FOR MEETINGS SHALL

INCLUDE:

1. CLINICAL PROBLEM(S) (practice relevant clinical issues):

56-year old male with known HF involving both ventricles admitted with short-
ness of breath and jaundice with elevated alkaline phosphatase (250), direct bili-
rubin (4.8), and GGT (162) was found on presentation. No nausea, vomiting or
history of alcohol abuse.
Treatment interventions discussed:
Shortness of breath: Secondary to acute HF decompensation and
significantly improved with diuresis.
Jaundice: Abdominal ultrasound demonstrated gallstones in the
gallbladder with no biliary dilation. Liver echo texture was normal.

2. EVALUATION OF CURRENT TREATMENT INTERVENTIONS:

Initially, the elevated liver enzymes were considered obstructive in nature. Subse-
quently, based on ultrasound, it was thought to be congestive. Plan was to con-
tinue diuresis and discharge once stabilized. Outpatient recommendations: fol-
low-up LFT’s in 4-6 weeks and if still elevated, obtain viral hepatitis serologies.

3. IF NEEDED, A PLAN OR RECOMMENDATION(S) FOR IMPROVING OUTCOMES:

Hospital day #7: Enzymes remain elevated. GI consult was obtained for more de-
finitive exclusion of obstructive jaundice with MRCP and laboratory studies in-
cluding viral hepatitis serologies, iron studies, thyroid-stimulating hormone, anti-
nuclear antibodies, and antimitochondrial antibodies.

_____________________________________ ___________________________
NP Signature Date
_____________________________________ ___________________________
Primary Supervising Physician Signature Date

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 QI Meeting Form
Template

QUALITY IMPROVEMENT PROCESS – DOCUMENTATION FOR MEETINGS SHALL INCLUDE:

1. CLINICAL PROBLEM(S) (practice relevant clinical issues):

2. EVALUATION OF CURRENT TREATMENT INTERVENTIONS:

3. IF NEEDED, A PLAN OR RECOMMENDATION(S) FOR IMPROVING OUTCOMES:

SIGNATURE(s) OF THOSE ATTENDED AND DATES:

_____________________________________ ___________________________
NP Signature Date

_____________________________________ ___________________________
Primary Supervising Physician Signature Date

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PROOF OF REGISTRATION
CONTROLLED SUBSTANCES
REPORTING SYSTEM
Every NP who prescribes controlled substances shall enroll and utilize the Controlled Substances Reporting
System (CSRS) within 30 days after obtaining an initial or renewal approval to practice that confers the au-
thority to prescribe a controlled substance for providing medical care for a client.

21 NCAC 36 .0809 (b)(2-6)

(2) Controlled Substances (Schedules II, IIN, III, IIIN, IV, V) defined by the State and Federal Controlled Sub-
stances Acts may be procured, prescribed, or ordered as established in the collaborative practice agree-
ment, providing all of the following requirements are met:
(A) the nurse practitioner has an assigned DEA number that is entered on each prescription for
a controlled substance;
(B) refills may be issued consistent with Controlled Substance laws and regulations; and
(C) the primary supervising physician(s) shall possess a schedule(s) of controlled substances
equal to or greater than the nurse practitioner's DEA registration.
(3) The nurse practitioner may prescribe a drug or device not included in the collaborative practice
agreement only as follows:
(A) upon a specific written or verbal order obtained from a primary or back-up supervising
physician before the prescription or order is issued by the nurse practitioner; and
(B) the written or verbal order as described in Part (b)(3)(A) of this Rule shall be entered into
the patient record with a notation that it is issued on the specific order of a primary or back-
up supervising physician and signed by the nurse practitioner and the physician.
(4) Each prescription shall be noted on the patient's chart and include the following information:
(A) medication and dosage;
(B) amount prescribed;
(C) directions for use;
(D) number of refills; and
(E) signature of nurse practitioner.

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(5) Prescription Format:
(A) all prescriptions issued by the nurse practitioner shall contain the name of the patient
and the nurse practitioner's name and telephone number;
(B) the nurse practitioner's assigned DEA number shall be written on the prescription
form when a controlled substance is prescribed as defined in Subparagraph (b)(2) of
this Rule.
(6) A nurse practitioner shall not prescribe controlled substances, as defined by the State and
Federal Controlled Substances Acts, for the following:
(A) nurse practitioner's own use;
(B) nurse practitioner's supervising physician;
(C) member of the nurse practitioner's immediate family, which shall mean a:
spouse; parent; child; sibling; parent-in-law; son or daughter-in-law; brother or
sister-in-law; step-parent; step-child; or step-siblings;
(D) any other person living in the same residence as the licensee; or
(E) anyone with whom the nurse practitioner is having a physical, sexual, or emotionally
intimate relationship.
(c) The nurse practitioner may obtain approval to dispense the drugs and devices other than samples
included in the collaborative practice agreement for each practice site from the Board of Pharmacy,
and dispense in accordance with 21 NCAC 46 .1703 that is hereby incorporated by reference including
subsequent amendments.

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Questions?
For questions pertaining to
elements in this guide, contact:
[email protected].
984-238-7675

To renew your NP approval to practice,

update supervising physician, etc., use
the Nurse Gateway, a single portal
used to submit and manage all
licensure and listing applications.

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