They’re a Fundamental Requirement – and a Necessary Protection – for NPs in California

By Melanie Balestra, NP, Esq.

Standardized procedures are required in any practice with NPs. One of the first things that the Board of Registered Nursing (BRN) requests in any disciplinary proceeding is to review the NP standardized procedures (SPs). If the SPs do not meet the BRN standards, that alone is grounds for probation.

I get many emails from NPs “working” on their SPs while in practice. An NP cannot start day one on a job without SPs in place signed by the NP, collaborating physician, and administrator. Many times physicians will say not to worry, they are working on them. Another excuse is that the practice attorney needs to review them. Not many attorneys have a clue as to what needs to be in the SPs, and it is not the attorney who will be practicing per SPs. However, the BRN does not accept any of these excuses and does not go after the physician, nor does the Medical Board. The NP is the one who can be placed on probation by the BRN for not having SPs in place.

If an NP works at multiple facilities, such as SNFs or multiple offices, s/he must have each office address listed in the SPs and s/he must have a copy of the SPs at each facility or office signed by her/him, the physician, and the administrator. The NP cannot just carry the SPs around with him/her. They have to be in a designated place at the facility where they can easily be found and utilized.

The NP starts doing a new procedure that is not covered in the SPs. This can be considered practicing outside the NP’s scope of practice. Always keep procedures and references for any procedures updated and current. If learning a new procedure, the NP needs to keep a written record of any didactic, clinical experiences and evaluations.

The BRN requires a formulary. The NP cannot simply state to refer to Epocrates or similar. Every drug that you furnish must be listed. This can be done by category. Don’t forget patient-specific protocols for Schedule II drugs must be in the SPs.

There are two types of protocols that can be developed 1) medical model, where every disease and treatment is listed, or 2) process protocols, which are divided into Primary, Secondary and Tertiary diagnoses and level of treatment. The BRN has an example of standardized procedures and protocols on their website, or you can refer to a book and CD “Process Protocols” by Rebecca Zettler, which is very thorough.

Every physician should be familiar with the NP’s SPs. A favorite question by investigators to physicians is “What is on the SPs?” If the physician has never read or participated in developing the SPs, s/he will have no idea what is actually written in the SPs. The investigator’s report then states that the collaborating physician is not familiar with the SPs. The BRN may then interpret this to mean that the NP and physician do not have much of a collaborating relationship. Therefore, make sure your collaborating physician is familiar with the SPs.

Bottom line, do not practice one day without SPs.  Make sure that your collaborating physician has read and is familiar with SPs. Make sure that everything that needs to be included in SPs is included.

Melanie Balestra is both an attorney and a nurse practitioner. She is a former President of CANP, and is currently President of the American Association of Nurse Attorneys, which in 2016 honored her with the award for Outstanding Health Law & Compliance Section Member. She has law offices in Irvine and Newport Beach, and continues to work part time as a PNP and Director of Pediatrics at the Laguna Beach Community Clinic.