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This morning, I’m excited to feature the scope of practice for NP’s in my beloved state of residence, Tennessee.  Not only does this great state feature a Dolly Parton-based theme park, the home of Elvis Presley and boast a spirit of volunteerism, Tennessee has pretty favorable laws toward NP’s.  Recent rankings show Tennessee is overall the 3rd freest state in our nation.  Fortunately, this attitude of freedom and independence extends to state laws governing nurse practitioners.

Let’s take a look at the rules and regulations governing nurse practitioners in the Volunteer State.

Tennessee’s Nurse Practitioner Supervision Laws

While Tennessee does require NP’s to be supervised by a physician, these rules are lax compared to many other states.  TN State Law defines a supervising physician as “a licensed and actively practicing physician who has been identified as accepting the responsibility for supervising certified nurse practitioners”.  Within this supervision agreement, Tennessee law outlines a few specific requirements:

  1. The supervising physician must be available for consultation with the NP at all times. This does not mean the physician need to be physically present or practicing in the same location as the nurse practitioner.  If the physician cannot be available for any reason, they must make arrangements for a substitute physician to be available.
  2. The supervising physician must have experience or expertise in the same area of medicine as the nurse practitioner.
  3. A written practice protocol must be in place outlining an acceptable standard of patient care.  The physician and NP are responsible for reviewing and updating this protocol biennially.  Copies must be maintained at each practice site.
  4. Once every ten business days, the supervising physician must review the nurse practitioner’s charts if medically indicated, requested by the patient or when a controlled medication has been prescribed.
  5. The supervising physician is responsible for reviewing at least 20% of the NP’s charts every 30 days.
  6. The supervising physician’s name and contact information must be listed on any prescriptions written by the nurse practitioner.  The physician’s signature is not required.

Overall, nurse practitioners are required to be loosely supervised by physicians in Tennessee.  The physician must comply with mandatory site visits and chart reviews as well as be available to the nurse practitioner at all times but not necessarily in person.

Tennessee’s Nurse Practitioner Prescribing Laws

In Tennessee, nurse practitioners are allowed to prescribe medications with physician supervision.  The physician’s name and contact information along with the nurse practitioner’s name and contact information (address and phone number) must be present on the prescription.  Before prescribing medication, as in all states, NP’s in TN must apply for and receive a license to prescribe from the DEA.

Nurse practitioners in Tennessee are allowed to prescribe controlled substances.  TN Law acknowledges that prescribing medications for and treating chronic pain is tricky and many patients abuse the system.  It encourages nurse practitioners to use judgement when prescribing pain medications while ensuring that individuals with pain are adequately treated.  Should a nurse practitioner choose not to treat a patient’s pain, they must make an appropriate referral to another provider for further evaluation and treatment.

TN State Law specifically prohibits NP’s from prescribing or issuing drugs whose sole purpose it to perform an abortion.

Other Scope of Practice Laws in Tennessee

Under TN State Law, nurse practitioners are not allowed to sign death certificates.  They are, however officially recognized as primary care providers and are allowed to sign handicap parking permits.

Are you a nurse practitioner in Tennessee?  Let us know about your experience!  Do you feel that the laws are favorable towards NP’s or do they present problems in your daily practice?

 

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16 thoughts on “Nurse Practitioner Scope of Practice: Tennessee”

  • I’ve moved from Kentucky recently where only a collaborating agreement between NP and me is required which does not lay any responsibility on the physician only that the MD will be available for collaboration in regards to writing non scheduled medications. Being a TN NP feels like a step backward in my opinion. The American Medical Association is not nursing’s regulatory body and MD’s should not have their fingers in our practice nor is it fair to the. To have to resume responsibility for another profession. It’s the AMA’s way of keeping MD’s in the $. NP’s have 50+ yrs of proven safety and equal if not superior care to MD’s.

  • I agree with the above comment from “Melissa”. I am from Texas and their laws are specific but concise. The Board of Nursing in Texas offers a pocket size handbook regarding delegation rules which I carried with me at all times. My experience with the Tennessee BON has be very negative with “I don’t know” being the most common answer to any question – a bunch of idiots!!! If you are a nurse practitioner in Tennessee watch your back, protect yourself, your profession and your integrity as a nurse. If you finally get a answer to questions regarding your practice in Tennessee keep a record of the name of the person you talked to, their response, the date and time of the conversation. Remember Tennessee BON=idiots!

  • Tennesee is indeed a VERY Backward state. The TBON should be dealing with any issues with the practice of NPs NOT MDs who feel threated by nurses, who practice within their scope.
    I am extremely dismayed that those MDs or others who realize that they are not able to practice eg psychriatic treatment would not have NPs for referrals. These clients/individuals would ultimately not get the tx needed. I have been advised to give money for political persons to advocate on “OUR” behalf as the MDs are doing this! (against NP, obviously)
    Unfortuanately it is a money talks society now and to approach based on concepts of suffering, need, service does not carry sufficient weight. When I can move out of this state, after spending my life to date here, I will be most happy- wish me luck and please don’t move to TN if can be avoided.

  • I find the “superior to MD” comment an indication that more stringent reviews and supervision is required of midlevels. Attitudes like this are dangerous to the patient. In less than 6 months, a midlevel has lacked the knowledge to recognize dangerous laboratory values, risk to patients in choice of medications, and arrogantly refused supervision as directed in our practice, responding ” I think I am capable to make the decision without discussion every time”.
    My question is, what kind of guidance and additional support do we the public get to maintain control of the arrogant, underqualified ( I want my MD who knows medicine and the effects positive and negative any drug might have on me handling my care, not a 3 quarter course in pharmacology rn who thinks they know enough if not more than qualified Doctors just because they passed) …where’s the safety for patients when NPs act like that?

  • Sounds like you have some problems with arrogance to me. A new grad NP certainly needs some guidance and help along the way, not overbearing arrogant MD breathing down her/his neck. There is much ignorance about the training a NP has and obviously you have as much as the next person, but obviously you are a Dr. with some axes to grind. The “superior to MD” care is based on MANY reviews and is outcome based, not based on one person in a practice who obviously has problems. Grow up and act your age.

  • Wow! I see that times are slow to change in the state of Tennessee. As an Advanced Practice Nurse, working on dissertation for a PhD, with a wide breath of knowledge and experience practicing in the military independently – I detest the term “midlevel”. I also detest the manipulation of minds or poor understanding of others and the public of what the differences are between our educated nurses. I am sorry to hear the “anonymous” comment above questioning guidance and additional support for the “public to maintain control of the arrogant, underqualified….”. That is a shame. It is unfortunate that this person has a closed-off mindset on what our profession can offer. To the same extent, the less we are allowed to practice – the more these feelings of mistrust and misgivings will continue. I almost debate switching to another state with more autonomy – like Idaho or some of the others….I will have to change my state of residence, but if as a practicing provider I am going to be mandated by my state to be attached to another provider that might or might not have the knowledge and experience I have….then, I will burn out quickly. I feel all providers – MDs, DOs, APNs, PT, Pharm-Ds should be granted the authority they were trained for as they all cohort with each other in order to give the best care for their patient. Nurses have been one of the most trusted professions for years. Why can’t we trust them to practice to capacity?

  • Sharon Psych Nurse Practitioner says:

    Hello,

    I am from CT where our laws allow nurse practitioners to work fully independent (after about 3 years). I read your laws as I am considering moving over there but this form of supervision is more like babysitting and one would suggest you look at CT’s laws and consider having nurse practitioners in TN become fully independent as well.

  • Aurele Psych APRN CT says:

    I am also from CT and agree that the supervision laws in Tennessee need an update. I have been a successful Psych APRN with 25 years experience, and it would seem like going backwards after practicing in CT. I too am looking at relocation options. I’m not sure I’m ready to go back to this level of supervision after so many years. But I love the tax environment in TN much better than CT.

  • We will just have to start having nurse practitioners complete a residency. I’m sure you guys won’t have any problem with that right? Until then, you should probably stop complaining about having a limited practice. To say that a nurse practitioner is equal to a physician who has had at least eight years of schooling plus a residency that was at least three years is ludicrous. Sidenote, I’m not sure if you have looked at the acceptance rates for medical school, but they hover around 10%. Medical school is more competitive to gain acceptance to then NP school ever thought about being. Maybe nurse practitioners should have to take the MCAT? Right? Furthermore, the basic science training physicians undergo is undeniably more difficult and demanding and goes into much more detail. If you don’t agree with that, I’m sure you would be happy to have nurse practitioners take the USMLE. Right? I didn’t think so.

  • I am a BSN, RN and currently in FNP school in TN. At one point I was considering med school (taking the necessary pre-reqs -organic chem, etc) but then changed to FNP route. I agree with “anonymous” in that the training and testing (MCAT, USMLE) for MD/DOs is more extensive compared to NP. However, evidence has shown that malpractice IS NOT GREATER with NPs vs MDs.

    So the question remains- did all that schooling/residency really help the MD be a better provider than the NP in regards to patient outcomes?

    The goal is to improve health and prevent illness. We should all work together and lean on each other. Respect the MD. Respect the NP. We are in this together!

  • The physicians who own practices that employ us love us because we save them money while giving great quality care. Those that do not own a practice are most often threatened by us and will complain regardless. I know several people who only want to see MD’s but I see a ton more who only want to see a NP because we collaborate with patients and care for them more holistically. Treating them like an individual and not a number goes a long way.
    Concerning the laws I think it could be a double edged sword. Whereas there is not very much there but at the same time you feel you could be thrown under the bus for the same reason. Still pondering this same question.

  • I do feel that a requirement, (like some other states, require), requiring at least five years as an RN in either an ER or ICU would be a bonus before allowing an NP to practice independently. Or, an NP for three years with the two years as a working RN. I have a few ER medical director friends, and IR interventionalists that trust the experienced nurse’s judgment, I have 25 years of RN experience and am currently in NP school, switching to the DNP program. I have spent almost 3 years now as a critical care radiology nurse specialist and am comfortable with my skills at recognition of issues on an MRI. I would never interpret the MRI but would consult with the radiologist for an accurate read. I am not being mean when it comes to recommendation for years as a RN, but it takes time to put it all together. For example, we have had NP’s with just two years as an RN, that order MRI’s to VERIFY a visible fracture on the x-ray that the radiologist confirmed with the read. Not sure how the insurance companies feel about that. It takes time to gain the skills to be comfortable with independence. I wouldn’t trade my years of experience working open heart OR, trauma OR charge nurse on weekends, night shift, occupation health nurse at GM. CVICU, TSICU, NCC night shift, and level I trauma ER night shift. There are young NP’s that are great about consulting with their co-worker NP’s, radiologists, and MD’s when their not comfortable with the difficult patient.
    As far as APRN rules and regulations: contact the BON, and then your state government. Diane Black is an RN from TN and is a representative in Washington. There need to be more specific guidelines written and easily accessible for nurses and consumers on the website.

  • Pamela Gunnell APRN,BC, FNP-C says:

    We need legislation to abolish the collaboration requirement In Tennessee…..and in the other 10 states of the union where they still exist. We know how to practice within our licensed scope of practice as defined by the State Board of Nursing. We still have collaboration with MD’s in our communities, just as MD’s collaborate with each other. We also have over-site by Medicare and insurance companies just like MD’s do.
    We should be able to sign death certificates: NP’s can diagnose death, we are not naive of the process.
    And we REALLY need to be allowed to sign Home Health and Nursing Home Orders, which we currently cannot: I doubt any of us would abuse the system or approve something unnecessary.
    And finally, for God’s sake, allow us to sign for diabetic shoes when the patient meets requirements and insurance benefits: this should not require an MD signature. NPs diagnose neuropathies, callus, hammertoes, bunions and ulcers. This rule is ridiculous. We do order prosthetics and medical equipment for our patients, why not a pair of diabetic shoes?

    The MD family primary care physician is dwindling in medical schools because there’s more interest in being a specialist in Internal Medicine and the other specialties. So, let Nurse Practitioners take care of the patient’s everyday complaints in Family Practice, so MD specialists can take care of what really interests them. We refer to you daily.
    Thank you for listening. Sincerely.

  • NP do not have the training of medical doctors yet most feel they know as much as any doctor.
    I have suffered from depression for many years and I WOULD NEVER LET A PSYCHIATRIC NP TREAT ME. The comments above only add to the arrogance of those who think they are doctors.
    A NP falls far short of an MD !!

  • Sherri Robertson says:

    I own the practice, I have been practicing for 10+ years. I am required to pay a physician thousands of dollars per year to “Supervise” pay for my own malpractice insurance and DEA. The $$ is what Supervising physicians is all about. I work extremely hard, long hours, and see patients who most physicians don’t want to be bothered with for a multitude of reasons, usually small reimbursements. Medical students spend 2 years in the class room, and 2 years clinical rotations. Their undergrad degree may be in anything. Our undergrad degree is in nursing, our clinical rotations are required the entire time. So after 7-8 years of medical education with clinical rotations the entire time, I do not consider myself a “mid level” and I should not have to pay exorbitant fees to a “supervisor’.

  • A concerned NP says:

    Wow I am not sure where to begin after reading all of these attacks at each other. First, let’s be clear. Past education requirements verses current education requirements for NPs is very different. Currently NPs spend (as stated by Sheri) 7-8 years of classroom and clinical combined. The RN takes 4-5 years to obtain. At least two years of that has clinical and classroom going at the same time. To become a NP adds an additional 3 years in whatever specialty they chose with, depending on the state, around 720 clinical hours. Let’s also remember that NPs are working as RNs. That is also training. We all know there is nothing like on-the-job training. Doctor’s spend 4-5 years getting their bachelors in various fields (but they do have certain classes they must have taken). Then they go to school to learn based on whatever specialty they get into. Now getting into programs is competitive not matter the field. My RN school only accepted 100 students, even though more than 800 students applied each semester. NP school also has requirements that have to be met in order to get accepted. But remember NP school is for the person who has already proven themselves to be capable. The weed-out process has already happened. So no it is not only 10% getting in, as we are already working professionals, which doctors are only students with no experience when trying to get into medical school. Both RN/NP and MD have testing they have to do to get in and to get out; as well as to obtain their licenses. The material covered in RN and NP school combined definitely covers the same material that is covered in MD school. The difference is that what NPs learned as RNs count, so when they go to NP school that material is not having to be crammed as much as MD schools. It is still indeed a lot of material and there are still people who do not make it. Now, on to the big difference. NPs do not get residency, like doctors do. I was a emergency RN at a teaching hospital; so trust me when I say residency is the key. As an RN I had to teach doctors how to care correctly for patients; what they need to order for meds and labs, care plans etc. We call them baby doctors because they indeed do not know much (but this does show you we know lab interpretations, medications, care plans, etc). As RNs we are tasked with making sure they did not mess anything up for the patients. We kept the patients safe, we told them yes and no. We did it all in respectful ways and helped them become the doctors they are today. In fact they are just as a new as NPs are. Since NPs do not get residency, then this is why you can more often find them needing more guidance (yes, I do feel something should be done to help with this issue). It is not that their education is lacking. I know this for a fact because I majored in Biological sciences to go to MD school, took MCAT, passed, got accepted, and decided not to go. I had my curriculum, I know the education used to be different and less for NPs, but it is not today. I decided to go back to get a second BS in nursing and go the NP route. I decided this because I wanted to have a more well-rounded education on caring for the whole patient. That is something that you get as a RN that you cannot get anywhere else. I say all of this to say. Everyone needs to stop attacking. There are some bad doctors, just like there are some bad NPs. I know doctors that call and learn from other doctors that have been around longer. NPs do need training and guidance, just like doctors do when they come out of school. There is a difference between training and guidance and just restricting. As a NP I can say there is very little if any training and guidance given, it should not be that way. As professionals we need to be able to collaborate and work together to better our patient care. We need to set our personal feelings aside and look at things objectively, look at all of the facts, stop assuming, and resolve the issues. Before and at the beginning of me becoming an RN, I spent 10 years as a patient going to doctors who could never tell me what was wrong with me. Some of them even treated me like I was crazy. After 10 years of suffering, it was a NP who correctly diagnosed me and got me back to health. A NP who works at a family owned doctor’s office and has been in a healthy environment that respects her profession and thus allows her to practice freely. Which has in turned developed her into the NP she is today. The same way doctors are respected and allowed to practice freely to develop into the doctors they are today. After reading these comments, I will definitely think twice about moving to Tennesse. Hostility is not the way to go, no matter the issue.

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