How does physician oversight work

[riquelle]

Hi! So I’m still a while off but eventually I would like to be an NP. I live in California which is one of the more restrictive states and I’m curious how the physician oversight works? I’ve had an NP as my pcp in the past and it didn’t seem any different than having a normal doctor, was she having to run everything by one in the background? And during clinical for my LVN program the provider in the ER was an NP sometimes so I’m just curious how that all works.

Thanks!

[Oldmahubbard]

The requirements in every state are different, but in no state does an NP have to run everything by a physician. It wouldn't be economically feasible.

Some states have a protocol book, a standard reference manual that the NP is supposed to adhere to. Treatment algorithms for things like HTN and DM. Of course, everything is not that cut and dried.

My state used to require a quarterly physician review of random charts. It was never specified how many. Apparently it was thought that such a review might protect the public, months after the fact.

Now try to get doctors to cooperate with the chart review every 3 months. It's neither enjoyable, nor income-producing. But the onus is on the NP to make sure the regulations are being followed.

Some states require a co-signature on narcotics. A few states require that the physician be physically present within a certain number of miles.

I do know that NP's in the past have been disciplined and fined by the BON in my state for failure to adhere to the regs.

Every work place will handle it differently. And it's up to you to make sure the minimum requirements are met.

It would be great if we all had wonderful collaborators who enjoy mentoring us, and don't mind the occasional phone call. But in the real world, your MD collaborator will probably be assigned the duty.

To answer your question, know your state regs. They surely are on the website. On a job interview, ask specifically about how the practice complies with NP supervision or collaboration.

For example, what happens when the MD goes on vacation or is ill?

In a perfect world, you would feel totally comfortable approaching your collaborator, and it would be easy to comply with the rules.

Bu that has not always been my experience.

Once again, the onus is on the NP.

[Corey Narry, MSN, RN, NP]

California requires NP's to establish "Standardized Procedures" mutually agreed upon with a physician. Standardized Procedures is a document that delineates the NP's specific roles such as evaluation and management of patients as well as furnishing (California's word for prescribing for NP's). The document can also include all medical procedures the NP will perform.

Interestingly, California law does not specify that the physician who signs the document must be physically present where the NP practices nor does it specify a limit as far as distance from the physical location of the physician and the physical location where the NP practices. It also doesn't require the physician to be licensed by the Medical Board of California.

Medi-Cal (the state's Medicaid program) designates Primary Care NP's as PCP's and bill them directly for their services.

The restriction on the NP license to have a physician sign off on a Standardized Procedure seems to be a function of formality rather than true supervision.

https://www.rn.ca.gov/pdfs/regulations/npr-i-25.pdf

[Oldmahubbard]

The moral of the story is that state laws differ widely and the NP has to know the applicable laws.

In my program, 20 years ago, I don't remember it ever being discussed. And there was a collaboration requirement at the time.

But we had nursing theory. What a pile of fecal matter.

[FullGlass, BSN, MSN, NP]

I'm also in California and MD oversight varies by the practice. At my previous job, there were random chart reviews of all providers. A new grad NP would get more chart reviews, of course. I very seldom had the CMO tell me anything that was "off" in my charts; she did periodically tell me I was doing well based on her chart reviews.

Other clinics have more MD oversight. So it depends on the practice. Honestly, most NPs in California function independently. The MD oversight here is just a way for MDs to line their pockets and it causes a lot of hardship in areas with provider shortages, such as rural areas.

[AddictionNP, MSN, NP]

I'm in California and my supervising physician comes once a week to sign charts. But I work in workman's comp so some documents have to have physician signature. as far as decision making, ordering medications and referrals, he has never told me or disagreed about any decisions I have made thus far. I'm a new grad (6 months) and always worry about missing things but he has nothing but positive feedback for my work so far...he is also a hand surgeon and very knowledgeable and is always willing to teach me new things.

[emsguy, MSN, APRN, NP]

It doesn't. They read some of your charting, and pretty much that it is, lame extra cost that takes away from NP's. When I was in California I wrote my own protocols. I had one supervising physician that did not understand the scope and role of my clinic and had to learn what we do, how we do it and so on. He is a great physician but was just out of his element.

[Oldmahubbard]

Don't expect the physician to know the laws.