Section 43-34-25 - Delegation of certain medical acts to advanced practice registered nurse; construction and limitations of such delegation; conditions of nurse protocol; issuance of prescription drug orders(a) As used in this Code section, the term: (1) "Advanced practice registered nurse" shall have the same meaning as provided in paragraph (1.1) of Code Section 43-26-3.(2) "Birthing center" means a facility or building where human births occur on a regular or ongoing basis and which is classified by the Department of Community Health as a birthing center.(3) "Controlled substance" means any controlled substance as defined in Code Section 16-13-21 but shall not include any Schedule I controlled substance included in Code Section 16-13-25 or any Schedule II controlled substance included in Code Section 16-13-26, except as authorized pursuant to subsection (d.1) of this Code section.(4) "Dangerous drug" means any dangerous drug as defined in Code Section 16-13-71.(5) "Delegating physician" means a physician who has entered into a nurse protocol agreement pursuant to this Code section.(6) "Diagnostic study" means a laboratory test, X-ray, ultrasound, or procedure used to identify a characteristic or distinguishing feature of a particular disease or condition.(7) "Drug" means any dangerous drug or controlled substance.(8) "Free health clinic" shall have the same meaning as provided in Code Section 51-1-29.4.(10) "Nurse protocol agreement" means a written document mutually agreed upon and signed by an advanced practice registered nurse and a physician, by which document the physician delegates to that advanced practice registered nurse the authority to perform certain medical acts pursuant to this Code section, and which acts may include, without being limited to, the ordering of drugs, medical devices, medical treatments, diagnostic studies, or radiographic imaging tests. Such agreements shall conform to the provisions set forth in subsection (c) of this Code section.(11) "Order" means to prescribe pursuant to a nurse protocol agreement which drug, medical device, medical treatment, diagnostic study, or radiographic imaging test is appropriate for a patient and to communicate the same in writing, orally, via facsimile, or electronically.(12) "Physician" means a person licensed to practice medicine under this article and:(A) Whose principal place of practice is within this state; or(B) Whose principal place of practice is outside this state but is within 50 miles from the location where the nurse protocol agreement is being utilized within this state.(13) "Prescription drug order" means a written or oral order of an advanced practice registered nurse for a drug or medical device for a specific patient. Such term includes an electronic visual image prescription drug order and an electronic data prescription drug order.(14) "Professional sample" means a complimentary dose of a drug, medication, medication voucher, or medical device provided by the manufacturer for use in patient care.(15) "Radiographic imaging test" means a computed tomography, magnetic resonance imaging, positron emission tomography, or nuclear medicine.(b) In addition to and without limiting the authority granted pursuant to Code Section 43-34-23, a physician may delegate to an advanced practice registered nurse in accordance with a nurse protocol agreement the authority to order drugs, medical devices, medical treatments, diagnostic studies, or radiographic imaging tests or to sign death certificates. A selection box shall be added to death certificates to be checked off by nonphysicians completing the form.(c) A nurse protocol agreement between a physician and an advanced practice registered nurse pursuant to this Code section shall:(1) Be between an advanced practice registered nurse who is in a comparable specialty area or field as that of the delegating physician;(2) Contain a provision for immediate consultation between the advanced practice registered nurse and the delegating physician; if the delegating physician is not available, the delegating physician for purposes of consultation may designate another physician who concurs with the terms of the nurse protocol agreement;(3) Identify the parameters under which delegated acts may be performed by the advanced practice registered nurse, including without limitation the number of refills which may be ordered, the kinds of diagnostic studies which may be ordered, the extent to which radiographic imaging tests may be ordered, and the circumstances under which a prescription drug order may be executed. In the event the delegating physician authorizes the advanced practice registered nurse to order an X-ray, ultrasound, or radiographic imaging test, the nurse protocol agreement shall contain provisions whereby such X-ray, ultrasound, or radiographic imaging test shall be read and interpreted by a physician who is trained in the reading and interpretation of such tests; a report of such X-ray, ultrasound, or radiographic imaging test may be reviewed by the advanced practice registered nurse; and a copy of such report shall be forwarded to the delegating physician, except that such provision for an ultrasound shall not be required for an advanced practice registered nurse acting within his or her scope of practice as authorized by Code Sections 43-26-3 and 43-26-5;(4) Require documentation either in writing or by electronic means or other medium by the advanced practice registered nurse of those acts performed by the advanced practice registered nurse which are specific to the medical acts authorized by the delegating physician;(5) Include a schedule for periodic review by the delegating physician of patient records. Such patient records review may be achieved with a sampling of such records as determined by the delegating physician;(6) Provide for patient evaluation or follow-up examination by the delegating physician or other physician designated by the delegating physician pursuant to paragraph (2) of this subsection, with the frequency of such evaluation or follow-up examination based on the nature, extent, and scope of the delegated act or acts as determined by the delegating physician in accordance with paragraph (3) of this subsection and accepted standards of medical practice as determined by the board;(7) Be reviewed, revised, or updated annually by the delegating physician and the advanced practice registered nurse;(8) Be available for review upon written request to the advanced practice registered nurse by the Georgia Board of Nursing or to the physician by the board; and(9) Provide that a patient who receives a prescription drug order for any controlled substance pursuant to a nurse protocol agreement shall be evaluated or examined by the delegating physician or other physician designated by the delegating physician pursuant to paragraph (2) of this subsection on at least a quarterly basis or at a more frequent interval as determined by the board.(d) A written prescription drug order issued pursuant to this Code section shall be signed by the advanced practice registered nurse and shall be on a form which shall include, without limitation, the names of the advanced practice registered nurse and delegating physician who are parties to the nurse protocol agreement, the patient's name and address, the drug or device ordered, directions with regard to the taking and dosage of the drug or use of the device, and the number of refills. A prescription drug order which is transmitted either electronically or via facsimile shall conform to the requirements set out in paragraphs (1) and (2) of subsection (c) of Code Section 26-4-80, respectively.(d.1) An advanced practice registered nurse who has at least one year of post-licensure clinical experience and is in good standing with the board may be authorized under a nurse protocol agreement to issue prescription drug orders for hydrocodone, oxycodone, or compounds thereof in emergency situations pursuant to the following requirements: (1) The authorization is specifically included in the nurse protocol agreement;(2) The advanced practice registered nurse has directly evaluated the patient;(3) The prescription drug order is limited to an initial prescription, not to exceed a five-day supply;(4) The prescription drug order is for an individual 18 years of age or older; and(5) The advanced practice registered nurse completes one hour of continuing education biennially in the appropriate ordering and use of hydrocodone, oxycodone, and compounds thereof.(e) An advanced practice registered nurse may be authorized under a nurse protocol agreement to request, receive, and sign for professional samples and may distribute professional samples to patients. The office or facility at which the advanced practice registered nurse is working shall maintain a general list of the professional samples approved by the delegating physician for request, receipt, and distribution by the advanced practice registered nurse as well as a complete list of the specific number and dosage of each professional sample and medication voucher received. Professional samples that are distributed by an advanced practice registered nurse shall be so noted in the patient's medical record. In addition to the requirements of this Code section, all professional samples shall be maintained as required by applicable state and federal laws and regulations.(e.1) Except for assigning a percentage of a disability rating, an advanced practice registered nurse may be delegated the authority to sign, certify, and endorse all documents relating to healthcare provided to a patient within his or her scope of authorized practice, including, but not limited to, documents relating to physical examination forms of all state agencies and verification and evaluation forms of the Department of Human Services, the State Board of Education, local boards of education, the Department of Community Health, and the Department of Corrections.(f) A managed care system, health plan, hospital, insurance company, or other similar entity shall not require a physician or advanced practice registered nurse to be a party to a nurse protocol agreement as a condition for participation in or reimbursement from such entity.(g) Except as otherwise provided in subsection (g.1) or (g.2) of this Code section, a delegating physician may not enter into a nurse protocol agreement pursuant to this Code section or enter into a job description with a physician assistant pursuant to Code Section 43-34-103 with more than the combined equivalent of eight advanced practice registered nurses or physician assistants at any one time, except this limitation shall not apply to an advanced practice registered nurse who is practicing: (1) In a hospital licensed under Title 31;(2) In any college or university as defined in Code Section 20-8-1;(3) In the Department of Public Health;(4) In any county board of health;(4.1) In any community service board;(5) In any free health clinic;(6) In a birthing center;(7) In any entity: (A) Which is exempt from federal taxes pursuant to Section 501(c)(3) of the Internal Revenue Code, as defined in Code Section 48-1-2, and primarily serves uninsured or indigent Medicaid and Medicare patients; or(B) Which has been established under the authority of or is receiving funds pursuant to 42 U.S.C. Section 254b or 254c of the United States Public Health Service Act;(8) In any local board of education which has a school nurse program;(9) In a health maintenance organization that has an exclusive contract with a medical group practice and arranges for the provision of substantially all physician services to enrollees in health benefits of the health maintenance organization; or(10) Notwithstanding the provisions of subsection (d.1) of this Code section, in any emergency medical services system operated by, or on behalf of, any county, municipality, or hospital authority with a full-time physician medical director and who does not order drugs, except that he or she may order up to a 14 day supply of drugs as necessary in an emergency situation, excluding benzodiazepines and all Schedule II controlled substances except hydrocodone, oxycodone, or compounds thereof; provided, however, that an advanced practice registered nurse shall not order radiographic imaging, diagnostic studies, or medical devices pursuant to this paragraph; and provided, further, that a patient shall be referred to a physician, a dentist, or a federally qualified health center.(g.1) A delegating physician may not enter into a nurse protocol agreement pursuant to this Code section or enter into a job description with a physician assistant pursuant to Code Section 43-34-103 with more than the combined equivalent of eight advanced practice registered nurses or physician assistants at any one time, may not supervise more than the combined equivalent of eight advanced practice registered nurses or physician assistants at any one time pursuant to nurse protocol agreements or job descriptions, and shall not be required to conduct any meetings, observations, or review of medical records except as otherwise provided in this subsection, if the advanced practice registered nurses practice at a location that: (1) Maintains evidence based clinical practice guidelines;(2) Is accredited by an accrediting body, approved by the board, such as the Joint Commission or a nationally recognized accrediting organization with comparable standards;(3) Requires the delegating physician to document and maintain a record of review of at least 10 percent of the advanced practice registered nurses' medical records to monitor quality of care being provided to patients, which may be conducted electronically or on site;(4) Requires the delegating physician and advanced practice registered nurse to participate in and maintain documentation of quarterly clinical collaboration meetings, either by telephone, in person, or on site, for purposes of monitoring care being provided to patients; and(5) Requires the delegating physician's name, contact information, and record of the visit to be provided to the patient's primary care provider of choice with the patient's consent within 24 hours of the visit.(g.2) A delegating physician may not enter into a nurse protocol agreement pursuant to this Code section or enter into a job description with a physician assistant pursuant to Code Section 43-34-103 with more than the combined equivalent of eight advanced practice registered nurses or physician assistants at any one time or supervise more than the combined equivalent of eight advanced practice registered nurses or physician assistants at any one time in any emergency medical services system operated by, or on behalf of, any county, municipality, or hospital authority with a full-time medical director.(h) Nothing in this Code section shall be construed to create a presumption of liability, either civil or criminal, on the part of a pharmacist duly licensed under Chapter 4 of Title 26 who, in good faith, fills a prescription drug order of an advanced practice registered nurse issued pursuant to a nurse protocol agreement.(i) Nothing in this Code section shall be construed to apply to the practice of a certified registered nurse anesthetist.(j) Nothing in this Code section shall be construed to require an advanced practice registered nurse to be a party to a nurse protocol agreement in order to practice as a registered professional nurse or an advanced practice registered nurse as otherwise permitted by Article 1 of Chapter 26 of this title.(k) Nothing in this Code section shall be construed to authorize an advanced practice registered nurse to issue a prescription drug order for a Schedule I or II controlled substance, except as otherwise authorized pursuant to subsection (d.1) of this Code section, or authorize refills of any drug for more than 12 months from the date of the original order except in the case of oral contraceptives, hormone replacement therapy, or prenatal vitamins which may be refilled for a period of 24 months.(l) Nothing in this Code section shall be construed to allow an advanced practice registered nurse to perform an abortion or to administer, prescribe, or issue a drug order that is intended to cause an abortion to occur pharmacologically.(m)(1) The board shall have the authority to promulgate rules and regulations governing a delegating physician in order to carry out the intents and purposes of this Code section.(2)(A) Further, the board shall be authorized to:(i) Require that a nurse protocol agreement shall be filed by the delegating physician with the board within a reasonable time from the date of execution;(ii) Determine, after review of a filed nurse protocol agreement, if such nurse protocol agreement fails to meet accepted standards of medical practice as established by the board; and(iii) Require the delegating physician to amend any such noncompliant nurse protocol agreement in order to meet such accepted standards.(B) If a medical practice has an existing approved nurse protocol agreement and an alternate delegating physician or a change in the delegating physician within the same or similar specialty, such new nurse protocol agreement for the new alternate delegating physician or a change in the delegating physician, upon submission, shall be automatically deemed approved by the board.(C) If a delegating physician submits a nurse protocol agreement for a new advanced practice registered nurse and such nurse protocol agreement that has substantially the same terms and provisions as a nurse protocol agreement previously submitted by such delegating physician for another advanced practice registered nurse and approved by the board, the nurse protocol agreement for the new advanced practice registered nurse, upon submission, shall be automatically deemed approved by the board.(n) Except for practice settings identified in paragraph (7) of subsection (g) of this Code section, it shall be unlawful for a physician to be an employee of an advanced practice registered nurse, alone or in combination with others, if the physician is required to supervise the employing advanced practice registered nurse. Such conduct shall be subject to sanctions by the Georgia Board of Nursing as to the advanced practice registered nurse and the board as to the physician.(o) An advanced practice registered nurse shall be allowed to make a pronouncement of death pursuant to authority delegated by the supervising physician of the advanced practice registered nurse and to certify such pronouncement in the same manner as a physician.Amended by 2024 Ga. Laws 471,§ 2-1, eff. 5/1/2024.Amended by 2024 Ga. Laws 471,§ 1-3, eff. 7/1/2024.Amended by 2021 Ga. Laws 307,§ 43, eff. 5/10/2021.Amended by 2020 Ga. Laws 563,§ 1, eff. 1/1/2021.Amended by 2019 Ga. Laws 321,§ 43, eff. 5/12/2019.Amended by 2019 Ga. Laws 48,§ 6, eff. 5/12/2019.Amended by 2017 Ga. Laws 274,§ 1, eff. 7/1/2017.Amended by 2015 Ga. Laws 218,§ 2A, eff. 7/1/2015.Amended by 2011 Ga. Laws 244,§ 5-27, eff. 7/1/2011.Amended by 2011 Ga. Laws 110,§ 2, eff. 7/1/2011.Amended by 2009 Ga. Laws 243,§ 1, eff. 7/1/2009.