The Nurse Practitioner (NP) Survival Guide to North Carolina Board of Nursing Compliance Review Audits will answer many of your questions regarding Nurse Practitioner practice in North Carolina.
Is a current Registered Nurse license needed to practice as a Nurse Practitioner in North Carolina?
Yes, an active, permanent, unencumbered Registered Nurse license issued by North Carolina or a multistate privilege to practice issued by another compact state is required for approval to practice as a Nurse Practitioner in North Carolina. Individuals holding a temporary Registered Nurse license are not eligible for Nurse Practitioner approval to practice.
Is physician supervision required for Nurse Practitioner practice in North Carolina?
Yes. Registering a primary supervising physician and signing a mutually agreed upon collaborative practice agreement (CPA) with a supervising physician licensed by the North Carolina Medical Board is required for a Nurse Practitioner to practice in North Carolina. Quality Improvement (QI) meetings are also required monthly for the first 6 months of a new CPA and then every 6 months thereafter.
What is Nurse Practitioner Registration? Is it required?
Yes, Registration is required for use of the title Nurse Practitioner in North Carolina. Registration is not the same as a renewal or approval to practice; it is a one-time occurrence that can be completed with the first initial approval to practice or at any time if not seeking approval to practice.
What is Initial Approval to Practice?
Initial approval to practice is first-time approval to practice as a Nurse Practitioner in North Carolina. An online application for Initial Approval to Practice must be completed and approved by the North Carolina Nursing Board and Medical Board before beginning employment as a Nurse Practitioner.
What is an Approval Number?
The approval number is a unique number assigned to a Nurse Practitioner at the time of initial approval. This number must be included on all prescriptions written by the Nurse Practitioner.
How is the Nurse Practitioners scope of practice defined in North Carolina?
The Nurse Practitioner’s scope of practice is defined by formal academic graduate-level educational preparation (population-focused), national certification, and maintained competence. The Collaborative Practice Agreement is a mutual contract between the NP and their supervising physician which defines what the Nurse Practitioner can do within their current practice site (this may be more restrictive but not less restrictive than their actual scope of practice).
Practice setting does not define scope, what an NP is doing within that setting, determines whether the NP is within scope. In addition, it is understood that there can often be specialty or subspecialty overlap in care, and advanced practice nurses are expected to consult, collaborate, refer, or escalate care in the best interest of the patient.
What materials might be requested if I am audited by the Board?
Either electronic or paper documentation regarding registration and approval to practice, collaborative practice agreements, quality improvement process meetings, and continuing education must be available for the previous 5 years (21 NCAC 36 .0810 5b).
Do Nurse Practitioners have hospital admission privileges in North Carolina?
It depends on the hospital's credentialing policies. Admitting and discharging patients may be within the scope of practice for Nurse Practitioners provided that these functions are included in the CPA between the Nurse Practitioner and supervising physician and the hospital has policies and procedures allowing Nurse Practitioners to perform these functions.
What happens if a job or supervising physician is changed?
The Nurse Practitioner must receive the approval to practice notification from NCBON with the new supervising physician before practice (seeing patients) can begin. This update is completed in the Nurse Portal.
Does the Quality Improvement (QI) process start again each time supervising physicians are changed?
Yes, the QI must be initiated again each time supervising physicians change. Monthly meetings are required for 6 months to discuss practice-relevant clinical issues and quality improvement measures; then the QIs are conducted every 6 months thereafter. Maintain these records for up to 5 years.
What should be done when the relationship with a supervising physician is discontinued?
Update the physician information in your Nurse Portal account if you do not have a new position with a new supervising physician. There is no fee associated with requesting inactive status or removing a supervising physician.
What are the minimum number of practice hours required to maintain the Nurse Practitioner approval to practice?
Clinical practice hours are not always required to maintain national certification. In NC, if a Nurse Practitioner has not had active status or licensure for two years or more, then the Nurse Practitioner will be required to apply and complete an approved Nurse Practitioner Refresher Course. Contact appractice@ncbon.com for additional information and guidance.
What is a Collaborative Practice Agreement (CPA)?
The CPA identifies the drugs, devices, medical treatments, tests, and procedures that may be prescribed, ordered, and performed, as would be appropriate for the diagnosis and treatment of the common medical problems seen in the Nurse Practitioner’s practice. The CPA must state how the continuous availability of the supervising physician will be provided for ongoing supervision, consultation, collaboration, referral, and evaluation of care provided by the Nurse Practitioner. The CPA must be reviewed, signed, and dated annually by the Nurse Practitioner and supervising physician. Please see the following resource link for additional information -- NP Survival Guide
Is current national certification required for Nurse Practitioner approval to practice in North Carolina?
Yes, Nurse Practitioners must have and maintain national certification for approval to practice in North Carolina.
Can Nurse Practitioners prescribe refills for Schedule controlled substances?
Yes, prescriptive authority is part of the Nurse Practitioner approval to practice. Controlled substances may be prescribed and refilled consistent with controlled substance laws and rules which includes mandatory registration with the Controlled Substance Reporting System (CSRS) NC Controlled Substances Reporting System | NCDHHS.
Other helpful information can be found at https://www.ncbop.org/faqs/general-pharmacy-faqs.html
What information must be on the Nurse Practitioner's name badge?
The North Carolina 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 type of license or listing title when providing patient care.
Can collaborative practice agreements and quality improvement meetings be electronically signed by the NP and primary supervising physician?
Yes, using documentation signature software.
Does the North Carolina Board of Nursing approve graduate programs?
No, the Board only has authority over pre-licensure nursing programs, and not graduate level programs.
To be approved to practice as a nurse practitioner in North Carolina, you need to:
- successfully complete a graduate level NP program that is nationally accredited by CCNE (Commission on Collegiate Nursing Education) or ACEN (Accreditation Commission for Education in Nursing) (formerly NLNAC),
- pass an NP national certification examination through a national credentialing body accepted by the Board of Nursing.
Is the supervising physician required to be physically present at all times while the Nurse Practitioner is practicing?
No, onsite physical presence is not required; however, the supervising physician must be continuously available to the Nurse Practitioner for consultation by direct communication or telecommunication.
Can Nurse Practitioners prescribe controlled substances?
Yes, a Nurse Practitioner may prescribe controlled substances. The supervising physician must have at least the equivalent DEA registration as the Nurse Practitioner.
Are supervising physicians and back-up supervising physicians responsible for the medical acts of Nurse Practitioners?
Reference Rule 0801 (10) (a) and (12). Yes, supervising physicians are considered responsible for the medical acts of the Nurse Practitioner they supervise.
Is a backup supervising physician required in North Carolina?
No, a backup supervising physician is not considered mandatory. However, if the primary supervising physician is not consistently available for consultation, an NP would be expected to have one or more backup supervising physicians. A back up physician does not need to be registered in the Nurse Portal like a primary supervising physician but does need an attestation signature as an addendum to the CPA that they agree to supervise when the primary supervising physician is not available to the NP.
Are Nurse Practitioners required to have an NPI number?
No, a National Provider Identifier (NPI) number is not a requirement for approval as a Nurse Practitioner in North Carolina. An NPI is a unique 10-digit identification number issued to healthcare providers by the Centers for Medicare and Medicaid Services (CMS). The Board does not have authority to regulate reimbursement/payer issues.
What are the usual age ranges for the Nurse Practitioner roles?
For most roles, the current standard has moved away from delineated age-restrictions as most APRN regulators use lifespan, birth to young adult, or adolescence to adulthood/elderly etc. National certification organizations, professional organizations, and educational institutions establish the scope and standard guidelines for each APRN role. These documents address role, function, population served, and practice setting. They offer advanced practice registered nurses the parameters for practice within the limits established by formal academic education and national certification. Therefore, the population foci scope and standards guidelines are recommended as the initial resource in defining an individual APRN’s role, population foci, and specialty practice.
Can NPs sign death certificates? What if the NP does not have official confirmation of cause of death?
Yes, North Carolina G.S. 130A-115 authorizes nurse practitioners to sign a death certificate in a manner consistent with G.S. 90-18.2 (e1) Therefore, a nurse practitioner can certify a death if it is covered under their collaborative practice agreement and the decedent is within the NP’s population focus and scope of practice.
Why do the death certificates need to be signed no more than 3 days after death?
The 3-day period is clearly stated in the statute language of GS 130A-115(d).
The Office of the Chief Medical Examiner from N.C. Department of Health and Human Services verified that unsigned death certificates can cause delays that negatively affect the filing process, decedent care, and funeral service planning.
NPs are expected to complete death certificates with what clinical information and data is available and if it is within their scope, and this act is considered in good faith. Chapter 130A - Article 4
Of note, there is specific training required in order to use the system to electronically file death certificates. Not having this training can cause delays when completing a death certificate. The NC Department of Health and Human Services Vital Records Team provided the following information regarding training and access to the system called NCDAVE:
According to the NC Database Application for Vital Events (NCDAVE), the time-consuming paper-based process for death certificate registration has been replaced with NCDAVE. This stream-lined system allows for greater efficiency, increased data accuracy and consistency in reporting processes. Please contact vitalrecordstraining@dhhs.nc.gov if you have any training questions or concerns.
Do NPs or other APRNs need to carry their own liability insurance?
Although there is not an NC regulation that requires an APRN to carry their own liability coverage, an APRN can choose to hold liability insurance. Employers may provide liability for their providers. To obtain liability insurance and the amount is an individual choice.
I am an APRN in NC, what is considered a boundary violation
Boundary violations can be unintentional or intentional, like sharing identifiable patient information or scenarios, inappropriate relationships, as well as inappropriate use of photos, social media, or other electronic communication. For additional information on what is considered the national standard for boundary violations in nursing regulation, follow the link to the National Council State Boards of Nursing website -- Professional Boundaries | NCSBN
How should I introduce myself as an Advanced Practice Registered Nurse?
You are expected to introduce yourself, so the patient understands your role and title within their healthcare team. There are no APRN rules that restrict the use of an academic title; for example, if a CNM has earned their DNP or PhD, they can state, “Hello, I am Dr. Smith, a certified nurse midwife.” North Carolina Badge Law G.S. 90-640