Performance of Medical Acts by Registered Nurses

Subject:

Requested By: F. E. Epps Coordinator of Regulatory Section Office of Assistant Secretary for Alcohol and Drug Abuse

Questions: May standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, be carried out by a registered nurse?

 

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2. May those standing orders be carried out by a registered nurse when the medications described are controlled substances?

    

Conclusions: Standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, may be carried out by a registered nurse if that registered nurse has been approved by the Board of Medical Examiners to perform medical acts.

 

1.  
2. A registered nurse may not carry out standing orders of a physician which involve controlled substances even if that registered nurse has been approved by the Board of Medical Examiners to perform medical acts.

    

The primary question for determination is whether or not standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, may be carried out by a registered nurse.

G.S. 90-18 defines practicing medicine as "diagnosing or attempting to diagnose, treating or attempting to treat . . . or prescribing for or administering to, or professing to treat any human ailment, physical or mental or any physical injury to or deformity of any other person."

Any act which comes within this definition may be done only by a licensed physician unless the act is specifically authorized by another statute or regulation.

Certain acts are specifically authorized when they are performed by a registered nurse.

G.S. 90-18(14) specifically excepts from the definition of "practicing medicine": "The practice of nursing by a registered nurse engaged in the practice of nursing and the performance of acts otherwise constituting medical practice by a registered nurse when performed in accordance with rules and regulations developed by a joint subcommittee of the Board of Medical Examiners and the Board of Nursing and adopted by both boards."

These rules and regulations are codified as Subchapter 32E of the North Carolina Administrative Code, and are entitled "Approval of Registered Nurse Performing Medical Acts." These regulations define "registered nurse" as a "registered nurse who is functioning and performing medical tasks at the direction of or under the supervision of a physician licensed to practice medicine in North Carolina, and which nurse is approved by the board defined in the regulations as the Board of Medical Examiners of the State of North Carolina as being qualified by training and experience to perform the functions and tasks outlined in the application at the direction of or under the supervision of a physician."

Standing orders are specifically mentioned in the description of what is meant by the term "under the supervision of a physician." The regulations state that "The backup physician shall be available on a regularly scheduled bases for . . . review of the registered nurses’ practice, between conferences incorporating chart review and co-signing records to document accountability: prescribing within that practice setting, standing orders and drug protocol for interval between conferences to be part of this regular review and documentation." (32E NCAC .0001)

Thus, standing orders of physicians as described herein may be carried out by registered nurses who have been approved by the Board of Medical Examiners under the terms of the regulations and it is the opinion of this Office that the intent of the regulations is that only registered nurses approved by the board may carry out standing orders of a physician.

A secondary question to be determined is whether or not standing orders of a physician which name controlled substance as the medication to be given once it has been determined that certain conditions exist may be carried out by a registered nurse. The regulations state:

"When the proposed medical functions of a registered nurse include prescribing of drugs, the supervising (backup) physician and the registered nurse shall review the formulary approved by the North Carolina Board of Nursing and the Board of Medical Examiners of the State of North Carolina, and shall acknowledge in the application to the board that they are familiar with the formulary, and that the formulary will be a part of the incorporated in the approved standing orders. Changes in the formulary are to be approved by the board. In regard to changes, the approved formulary may include any over-the-counter or non-prescription drug.

Prescriptions, except controlled substances, (Emphasis ours) may upon specific orders of the supervising physician, given before the prescription is issued, be written and issued by such registered nurse for the use by patients of drugs which are not included in the formulary. . . . However, no prescription shall be written or issued by such registered nurse for any drugs which are specified as controlled substances under the Federal Controlled Substances Act." (32 E NCAC .0003)

Thus, it is the opinion of this Office that a registered nurse may not carry out standing orders which involve controlled substances.

Rufus L. Edmisten Attorney General

Ann Reed Special Deputy Attorney General