North Carolina Board of Nursing

Nursing Practice

Nurse Practitioner

FAQ - Nurse Practitioner (NP)

Registration / Approval to Practice (Initial and Subsequent Renewal)

  1. What is NP Registration?
  2. What is Initial Approval to Practice?
  3. What is Registration/Initial Approval to Practice?
  4. What is an Approval Number?
  5. What if I change jobs or primary supervising physicians?
  6. What is the turn-around time for completed applications?
  7. Do I need an RN license in order to be approved to practice as a Nurse Practitioner?
  8. Is current national certification required in order to receive registration or approval to practice?
  9. Must I include a photo on both the Registration and the Initial Approval to Practice Application documents?
  10. If I am planning to function as an NP in an office with one or more satellite sites, which site name should I place on the NP Approval to Practice Application?
  11. I was recently approved to practice and paid the application fee online. My birthday is now here. Do I need to pay the renewal fee so shortly after receiving my NP approval?
  12. I have just been initially approved to practice as an NP, but my NP renewal is due in a few months. Do I need to obtain 50 contact hours in order to renew for the first time?
  13. My NP approval to practice was made inactive for failure to renew. How do I reinstate?

Supervision / Scope of Practice

  1. What should I do when I discontinue my relationship with my primary supervising physician?
  2. Are primary supervising physicians and back-up supervising physicians responsible for the medical acts of NPs?
  3. How many supervising physicians are required to be designated for each NP?
  4. Must an NP have a back-up supervising physician?
  5. Is on-site presence of supervising physician required at all times the NP is performing tasks pursuant to the collaborative practice agreement?
  6. What should an NP do if an emergency affects the ability of her/his primary supervising physician to function in the supervisory capacity?
  7. What are the required credentials for physician supervision?

Prescriptive Authority

  1. May an NP prescribe controlled substances?
  2. Can an NP prescribe refills for Schedule III and IIIN controlled substances?
  3. May an NP prescribe controlled substances consistent with United States Drug Enforcement Administration (DEA) rule 21 CFR 1306.12 and not violate the Boards’ prescribing rules pertaining to nurse practitioners?
  4. Is a pharmacy permit to dispense required for a Nurse Practitioner to distribute sample medications to patients?

Practice

  1. Do NC rules for NPs apply to those employed by the federal government and working in a federal facility?
  2. What information must be on the NP’s name badge when the NP is involved in the direct provision of health care to patients?
  3. What does the Medical Board’s Position Statement on Referral Fees and Fee Splitting mean?
  4. Can Nurse Practitioners engage in telehealth/telemedicine?
  5. Can Nurse Practitioners practice in roles that are outside of their area of certification?

Education

  1. Does the North Carolina Board of Nursing (NCBON) approve post-licensure and graduate-level nursing education programs in NC and in other states?
  2. Is a Doctorate required for entry into practice as a nurse practitioner?

Registration / Approval to Practice (Initial and Subsequent Renewal)

1. What is NP Registration?

RNs that have completed an accredited NP program and have national certification may complete an online application for Registration so they may use the title Nurse Practitioner. Registration is required for all NPs seeking approval to practice after December 31, 2004. A Certificate of Registration will be emailed to the NP after the application is processed by the Board of Nursing. Registration does not confer the authority to practice. (See approval to practice below.)

2. What is Initial Approval to Practice?

Initial approval to practice is first-time approval to practice as an NP in North Carolina. An online application for Initial Approval to Practice must be completed and approved by the NC Medical Board and Board of Nursing (the Boards) prior to beginning employment as an NP. In addition to the online application, all supporting documentation must be received by the Board of Nursing before the application can be processed. The application instructions indicate what information must be submitted.

3. What is Registration / Initial Approval to Practice?

This is a combined online application that consists of both the Registration and Initial Approval to Practice applications. There is only one identification document for this combined application which will need a photo and signature of the NP.

4. What is an Approval Number?

The NP’s approval number is a unique number assigned to the NP at the time of initial approval. This number must be included on all prescriptions written by the NP.

5. What if I change jobs or primary supervising physicians?

NPs that change jobs or add new supervising physician(s) must complete the "Add Physician" online application via the Nurse Gateway. The NP shall not practice until notification of approval has been received. The approval letter and certificate will be emailed to the NP upon FINAL approval to practice with the new supervising physician. The approval can also be verified on the Board's website by selecting Verfiy License.

6. What is the turn-around time for completed applications?

All online applications are received by the Board of Nursing office on a daily basis. Due to the volume of applications received, please allow fifteen (15) business days for processing the application from the time all required documents are received in the Board office.

7. Do I need an RN license in order to be approved to practice as a Nurse Practitioner?

Yes. The NP must have an active, permanent, unencumbered RN license issued in North Carolina or an active, permanent and unencumbered RN license with a multistate privilege to practice issued by another compact state. Applications for individuals with a temporary RN license in either NC or a compact state can not be processed.

8. Is current national certification required in order to receive registration or approval to practice?

Yes. Beginning January 1, 2000, all NPs with first-time approval to practice in North Carolina must provide current evidence of certification as an NP by a national credentialing body accepted by the Boards.. Beginning January 1, 2005, NPs seeking initial approval to practice in North Carolina must be Masters prepared and have current national certification in the NP’s area of education and intended practice. As part of the registration application process, the NP must show proof of current national certification. See 21 N.C. Administrative Code 36 .0803 and 21 N.C. Administrative Code 32M .0103.

9. Must I include a photo on both the Registration and the Initial Approval to Practice Application documents?

Yes. A photo must be attached to the Registration application as well as to the Approval to Practice Application or with the combined application – Registration and Initial Approval - only one photo is required.

10. If I am planning to function as an NP in an office with one or more satellite sites, which site name should I place on the NP Approval to Practice Application?

If the primary supervising physician will be the same individual at all sites, the main office address should be listed as the principle site and the additional satellite sites(s) should be listed under the practice sites section. The NP must complete an additional online application for approval to practice for each site where the NP will have a different primary supervising physician.

11. I was recently approved to practice and paid the application fee online. My birthday is now here. Do I need to pay the renewal fee so shortly after receiving my NP approval?

Nurse Practitioner rules require that an NP renew the approval to practice online with the Board of Nursing annually by the last day of the birth month unless initial approval was issued within three months of your birth month. The renewal fee is required.

12. I have just been initially approved to practice as an NP, but my NP renewal is due in a few months. Do I need to obtain 50 contact hours in order to renew for the first time?

Between the time you are initially approved to practice as an NP and your first renewal, you are not required to obtain 50 contact hours. You are only required to obtain 50 contact hours AFTER your first NP renewal, and every NP renewal period (birth month to birth month) thereafter.

13. My NP approval to practice was made inactive for failure to renew. How do I reinstate?

For reinstatement of approval to practice, the NP must complete the NP Reinstatement application and pay the fee via the Nurse Gateway. The NP will be notified upon reinstatement of the NP's approval to practice. The approval can also be verified on the Board's website by selecting Verify License.

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Supervision / Scope of Practice

1. What should I do when I discontinue my relationship with my primary supervising physician?

The NP’s approval to practice is terminated when the NP discontinues working within the approved NP collaborative practice agreement, and the NP shall notify the Board of Nursing in writing. See Rules 21 NCAC 36 .0804 (d) and 21 NCAC 32M .0104 (d). This can also be done at: www.ncbon.com – request inactive status (no fee).

2. Are primary supervising physicians and back-up supervising physicians responsible for the medical acts of NPs?

Primary supervising physicians are responsible at all times for the medical acts of the NPs they supervise. Back-up supervising physicians are only responsible for the medical acts of NPs when they are actively supervising the NP.

3. How many supervising physicians are required to be designated for each NP?

An NP is only required to have one primary supervising physician.

4. Must an NP have a back-up supervising physician?

While it is not required that an NP have a back-up supervising physician, NPs are encouraged to have a designated physician available to her/him in the absence of her/his primary supervising physician. Back-up supervising physicians must be approved by the NP and the primary supervising physician. Nurse Practitioners must keep a copy of the form on file at all practice sites for which it applies, but do not send this form to either the Board of Nursing or the Medical Board. The form must be signed by the NP, primary supervising physician and the back-up supervising physician(s).

5. Is on-site presence of supervising physician required at all times the NP is performing tasks pursuant to the collaborative practice agreement?

On-site physical presence is not required; however, the primary or back-up supervising physician and the NP must be continuously available to each other for consultation by direct communication or telecommunication.

6. What should an NP do if an emergency affects the ability of her/his primary supervising physician to function in the supervisory capacity?

Emergency situation is defined as an injury, sudden illness, death or other unforeseen unavailability of the nurse practitioner’s primary supervising physician.

In an emergency situation the staff of both Boards are authorized to grant the nurse practitioner continued approval to practice until a new application is received and processed as follows:

(1) The nurse practitioner shall notify both Boards within two (2) business days of the emergency situation by first calling the Boards and then following up with a letter describing the emergency situation.

(2) The nurse practitioner is given forty-five (45) days from the date of the emergency situation to submit an application for a new primary supervising physician.

(3) The NP may ask for an extension of up to an additional 30 days if he/she is unable after an exercise of due diligence to find another primary supervising physician.

(4) If an application for a new primary supervising physician is not submitted within forty-five (45) days or if an extension is not granted, the nurse practitioner’s approval to practice will terminate.

7. What are the required credentials for physician supervision?

The supervising physician’s population focus, certification and maintained competence should mirror or exceed that of the NP to avoid limiting the NPs scope of practice. Per 21 NCAC 36 .0802 SCOPE OF PRACTICE (10), (12), Physician supervision is required for NP approval to practice in NC.

(10) "Primary Supervising Physician" means the licensed physician who shall provide ongoing supervision, collaboration, consultation and evaluation of the medical acts performed by the nurse practitioner as defined in the collaborative practice agreement. Supervision shall be in compliance with the following:

(a) The primary supervising physician shall assure both Boards that the nurse practitioner is qualified to perform those medical acts described in the collaborative practice agreement.

(b) A physician in a graduate medical education program, whether fully licensed or holding only a resident's training license, shall not be named as a primary supervising physician.

(c) A fully licensed physician in a graduate medical education program who is also practicing in a non-training situation may supervise a nurse practitioner in the non-training situation.

(12) "Supervision" means the physician's function of overseeing medical acts performed by the nurse practitioner.

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Prescriptive Authority

1. May an NP prescribe controlled substances?

Yes. An NP may prescribe controlled substances consistent with 21 NCAC 36 .0809 and 21 NCAC 32M .0109. A physician must have DEA registration equal to or greater than the DEA registration of an NP that he or she supervises.

2. Can an NP prescribe refills for Schedule III and IIIN controlled substances?

Yes. Due to a recent NP rule change (21 NCAC 36.0809 and 21 NCAC 32M .0109) effective April 1, 2011, the prohibition on refills for this class of drugs was removed. NPs may now prescribe up to 5 refills for Schedule III and IIIN controlled substances. Dosage units continue to be limited to a 30 day supply for each refill.

3. May an NP prescribe controlled substances consistent with United States Drug Enforcement Administration (DEA) rule 21 CFR 1306.12 and not violate the Boards’ prescribing rules pertaining to nurse practitioners?

Yes.

21 CFR 1306.12 (reprinted below) prohibits the refilling of Schedule II controlled substances.

Nurse Practitioner Rule 21 NCAC 36.0809(b)(2)(B) [21 NCAC 32m.0109(b)(2)(B)] mandates that NP prescriptions for Schedules II, IIN, III, IIIN controlled substances be limited to a 30 day supply.

Per 21 CFR 1306.12(b), under certain circumstances, a provider may issue multiple prescriptions for Schedule II controlled substances that result in a ninety (90) day supply. Those conditions are included in the rule reprinted below.

NPs who comply with 21 CFR 1306.12 are not in violation of the applicable NP rules regarding the prescribing of controlled substances so long as the NP strictly complies with all of the conditions enumerated in 21 CFR 1306.12.

In addition, the Boards’ position on this matter pre-supposes that the NP who prescribes pursuant to 21 CFR 1306.12 follows all other applicable rules pertaining to NP practice in North Carolina. The NP rules may be found in 21 NCAC 36 Section .0800 and 21 NCAC 32M and may be accessed at www.ncbon.com or www.ncmedboard.org.

21 CFR 1306.12

Section 1306.12 Refilling Prescriptions; Issuance of multiple prescriptions. (a) The refilling of a prescription for a controlled substance listed in Schedule II is prohibited.

(b)(1) An individual practitioner may issue multiple prescriptions authorizing the patient to receive a total of up to a 90-day supply of a Schedule II controlled substance provided the following conditions are met:

(i) Each separate prescription is issued for a legitimate medical purpose by individual practitioner acting in the usual course of professional practice;

(ii) The individual practitioner provides written instructions on each prescription (other than the first prescription, if the prescribing practitioner intends for that prescription to be filled immediately) indicating the earliest date on which a pharmacy may fill each prescription;

(iii) The individual practitioner concludes that providing the patient with multiple prescriptions in this manner does not create an undue risk of diversion or abuse;

(iv) The issuance of multiple prescriptions as described in this section is permissible under the applicable state laws; and

(v) The individual practitioner complies fully with all other applicable requirements under the ACT and these regulations as well as any additional requirements under state law.

(2) Nothing in this paragraph (b) shall be construed as mandating or encouraging individual practitioners to issue multiple prescriptions or to see their patients only once very 90 days when prescribing Schedule II controlled substances. Rather, individual practitioners must determine on their own, based on sound medical judgment, and in accordance with established medical standards, whether it is appropriate to issue multiple prescriptions and how often to see their patients when doing so.

4. Is a pharmacy permit to dispense required for a Nurse Practitioner to distribute sample medications to patients?

No. The Board of Pharmacy has indicated that the registration, permitting, and oversight requirements of Pharmacy Rule .1703 do not apply to an NP who is engaged in traditional sampling – that is, handing out, free of any charge (whether direct or indirect), starter doses or packets of prescription drug samples received from a prescription drug manufacturer in compliance with the Prescription Drug Marketing Act.

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Practice

1. Do NC rules for NPs apply to those employed by the federal government and working in a federal facility?

Federally employed NPs are governed by federal rules and regulations in regard to how they practice while working within federal facilities. However, a federally employed NP who holds a North Carolina approval to practice and wants to maintain the approval to practice must comply with NC rules that pertain to maintaining an active approval to practice (i.e. annual renewal, CE and payment of fees). Also, any NP actively approved to practice is expected to practice competently, act professionally and be of requisite good character no matter where, or for whom, he or she works.

2. What information must be on the NP’s name badge when the NP is involved in the direct provision of health care to patients?

The NC Badge Law (GS 90-640) requires every health care professional to wear or display a readily visible form of identification to include the individual’s name and the license, approval to practice or listing title when providing patient care. Standard abbreviations for such titles may be used as in Jane Smith, RN, NP. Exceptions to this requirement are outlined in Rule 21 NCAC 36.0231 Exceptions to Health Care Practitioners Identification Requirements.

Consistent with agency policy, the NP may choose to include academic or certification designations on the name badge, but these must be in addition to the NP’s legally approved practice title(s). For example, one might use Jane Smith, RN, NP, MSN or Jane Smith, RN, NP, PhD depending upon one’s level of academic preparation.

3. What does the Medical Board’s Position Statement on Referral Fees and Fee Splitting mean?

The position statement is intended to prevent physicians from sharing revenue they have generated on a percentage basis with a non-physician. The Medical Board’s position statement is not intended to prevent the NP employees from receiving a percentage of revenue they have generated (often referred to as a productivity bonus).

4. Can Nurse Practitioners engage in telehealth/telemedicine?

Yes. A Nurse Practitioner (NP) may practice within his/her designated scope of practice set forth in NC Laws and Rules using telehealth/telemedicine methods of healthcare delivery. Telehealth (interchangeably termed telemedicine) is the practice of healthcare within a professionally designated scope of practice using electronic communication, information technology, or other means between a licensee in one location and a client in another location with or without an intervening healthcare provider. The North Carolina Medical Board has a position statement on Telemedicine that can be used for guidance on training of staff utilizing telehealth, evaluations and examinations, licensee-client relationship, prescribing, health records, and licensure.

Any NP using telehealth to regularly provide services to clients located in North Carolina need not reside in North Carolina but must hold either a valid, unencumbered multi-state RN license, or a valid, unencumbered NC single-state RN license. Additionally, an NP must be both registered and approved to practice in NC. Approval to practice requires that an NP have a supervising physician and a collaborative practice agreement (CPA). The NP Scope of Practice is set forth and defined by the North Carolina Administrative Code (NCAC) NP Rules (21 NCAC 36 .0802 SCOPE OF PRACTICE) and operationalized through the CPA. Telemedicine activities should be clearly defined within the CPA. CPA guidelines are available at: http://www.ncbon.com/dcp/i/nursing-practice-nurse-practitioner-collaborative-practice-guidelines.

In NC, NPs are jointly regulated by both the NC Board of Nursing and the NC Medical Board. Please note that supervising physicians must hold a valid, unencumbered NC license. The NCBON recommends that the NP contact the NC Medical Board (www.ncmedboard.org) to assure full understanding of physician duties and responsibilities when entering into a CPA.

5. Can Nurse Practitioners practice in roles that are outside of their area of certification?

Additional areas of competence can be obtained and validated through additional education, certification (when available) and competence validation. The NP Scope of Practice are set forth and defined by the NP rules (21 NCAC 36 .0802 SCOPE OF PRACTICE) & operationalized by the Collaborative Practice Agreement (CPA). It is important for the CPA to clearly identify what drugs, devices, medical treatments, tests and procedures that may be prescribed, ordered and performed, would be appropriate for the diagnosis and treatment of the common medical problems seen in your NP practice sites. If a NP is considering practicing in an area that is outside of the scope of practice for which they have been educated, received national certification and competence validation, this would be considered beyond the scope of practice. A NP may expand their areas of competence if this is permitted by their employer policy and procedures and is not in violation of any other laws or rules. To develop additional areas of competence the NP may document how s/he obtained additional skill and competencies through education, specialty certification (if available) and maintained competence.

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Education

1. Does the North Carolina Board of Nursing (NCBON) approve post-licensure and graduate-level nursing education programs in NC and in other states?

No, the NCBON does not have jurisdiction in the approval of post-licensure and graduate-level nursing education programs within NC nor in other states. The NCBON does not approve RN to BSN programs, RN to MSN programs, RN to doctoral programs, masters programs, nor doctoral programs. This includes programs which prepare Advanced Practice Registered Nurses (APRN) as Nurse Practitioners (NP), Certified Nurse Midwives (CNM), Certified Registered Nurse Anesthetists (CRNA), and Clinical Nurse Specialists (CNS). The method of instruction (face-to-face, online, hybrid, or correspondence) does not influence the NCBON approval jurisdiction. Graduate-level nursing education programs are usually nationally accredited and may be required to be Board-approved in some states.

The NCBON approves and regulates pre-licensure Registered Nurse (RN) and Licensed Practical Nurse (LPN) education programs (i.e., programs leading to initial licensure) located within NC. The NCBON does not approve pre-licensure nursing education programs located outside of NC.

Out-of-state nursing education programs should be contacted directly for information and specific questions about the program and the program's approval/accreditation status in their state. It is recommended that individuals research the approval/accreditation status and educational outcomes of any nursing education program before enrolling in individual courses or the entire program of study.

There are two additional sources of information: UNC General Administration, and the NCBON website for further information.

UNC General Administration

Regarding the approval of out of state nursing programs, if there is a clinical component to the program that the applicant plans to meet in NC, the program needs to have approval from the University of North Carolina General Administration. Please contact the UNCGA at 919.962.4558. Please note this requirement is NOT from the North Carolina Board of Nursing.

All out of state institutions offering doctoral degrees licensed to offer specific degrees to North Carolina residents can be found in the preceding hyperlink. Select the institution to confirm if the degree you are interested in pursuing has been approved by the UNC Board of Governors. If you do not see the degree on the list, please contact the UNCGA for further information. This is a mandate from the United States Department of Education and not associated with the NC Board of Nursing. If the education program is truly a 100% online degree program that does not require a field experience, students may enroll.

The North Carolina Board of Nursing has jurisdiction only over generic nursing programs located in North Carolina that prepare graduates to take the initial licensure examination. You can find this citation in the North Carolina Nursing Practice Act 90.171.20 (5). Out of state programs are approved by the Board of Nursing in the state in which they reside. Please see 21 NCAC 36.0223 (attached) regarding the continuing education program rules that apply to your institution for graduate level education.

While some states do have jurisdiction over programs beyond those leading to initial licensure, North Carolina does not. Those programs that the NCBON does not have jurisdiction over include RN-BSN programs, masters and doctoral programs.

The NCBON

The NCBON maintains a list of graduate level APRN (MSN, Doctor of Philosophy or Doctor of Nursing Practice) programs in North Carolina which can provide a quick reference for APRN programs offered in NC.

2. Is a Doctorate required for entry into practice as a nurse practitioner?

No. As noted in 21 NCAC 36 .0805 EDUCATION AND CERTIFICATION REQUIREMENTS FOR REGISTRATION AS A NURSE PRACTITIONER, (a) A nurse practitioner with first-time approval to practice after January 1, 2000, shall provide evidence of certification or recertification as a nurse practitioner by a national credentialing body. (b) A nurse practitioner applicant who completed a nurse practitioner education program prior to December 31, 1999 shall provide evidence of successful completion of a course of education that contains a core curriculum including 400 contact hours of didactic education and 400 hours of preceptorship or supervised clinical experience.

On October 25, 2004, the member schools affiliated with the American Association of Colleges of Nursing (AACN) voted to endorse the Position Statement on the Practice Doctorate in Nursing. This decision called for moving the current level of preparation necessary for advanced nursing practice from the master’s degree to the doctorate-level by the year 2015. This endorsement was preceded by almost three years of research and consensus-building by an AACN task force charged with examining the need for the practice doctorate with a variety of stakeholder groups. While market forces may preferentially choose an NP with doctoral preparation, the NCBON regulations currently require a master's or higher degree for qualification for entry into practice as a NP.

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