All Advanced Practice Registered Nurses (APRN), pursuant to the Board of Registration in Nursing (Board) regulations at 244 CMR 4.00 are required to have practice guidelines and, when applicable, prescriptive guidelines. Guidelines are defined in regulation as "written instructions and procedures describing the methods that nurses practicing in an expanded role are to follow in managing a health care situation or resolving a health care problem and which specifies those instances in which referral to or consultation with a physician is required".

All of the Board regulations, which refer to a supervising physician, refer to the physician with whom the nurse has developed and signed guidelines. Additional criteria for the supervising physician are defined in the regulations at 244 CMR 4.05, 4.22, and 4.23. It is important that you be familiar with them. The Board of Medicine has promulgated regulations at 243 CMR 2.10, which further describe the role and responsibilities of the supervising physician.

Take a moment to review Preparing for APRN Practice to obtain information related to APRN practice requirements.

Advanced Practice Requirements

  • Current Massachusetts license as a Registered Nurse
  • Satisfactory completion of a formal educational program approved by the which has as its objectives the preparation of nurses to perform in the advanced practice role
  • Current certification from a national certifying body recognized by the Board
  • Written authorization by the Board to practice in the advanced role
  • Current dated guidelines pursuant to 244 CMR 4.22 and/or 4.23
  • For prescriptive practice: valid registration from the Massachusetts Department of Public Health in accordance with Massachusetts General Laws, chapter 94C, s. 7(g) and by the U.S. Drug Enforcement Administration

Advanced Practice means

  • Activities in accordance with 244 CMR 4.00
  • Employment of advanced skills including evaluation, diagnosis and treatment
  • Management of therapeutic regimes

Prescriptive Practice means

  • Issuance of written or oral prescriptions for a drug, substance, or immediate precursor in any schedule or class referred to in M.G.L. c. 94C or 105 CMR 700.000.

PLEASE NOTE: It is not legal to prescribe or write orders for any prescription drug or controlled substance until the appropriate state and federal registration numbers are issued.

All Board authorized APRNs who are seeking prescriptive authority in Massachusetts must register with the Massachusetts Department of Public Health- Drug Control Program (DPH-DCP). The application for a Massachusetts Controlled Substance Registration (MCSR) is available online at:

http://www.mass.gov/Eeohhs2/docs/dph/quality/drugcontrol/app_advanced_pn_pa_new_renew.pdf pdf format of Advanced Practice Nurse and Physician Assistant

For prescribing controlled substances in Schedules II - V, you must also obtain a Drug Enforcement Administration (DEA) registration number. To be eligible for a DEA number you must have a state Controlled Substance Registration Number or have an application pending for it from the DPH-DCP. The DEA application is available online at:

http://www.deadiversion.usdoj.gov/drugreg/reg_apps/onlineforms_new.htm

Educational requirement as of 1-1-11

As of January 1, 2011, pursuant to MGL 94C, Section 18(e), all prescribers, upon initial application for MA Controlled Substance Registration (MCSR) and subsequently during each APRN license renewal period, must complete education relative to:

  • effective pain management,
  • identification of patients at high risk for substance abuse, and
  • counseling patients about the side effects, addictive nature and proper storage and disposal of prescription medications.

Please note that MGL 94C, Section 18(e) does not specify a minimum number of contact hours to comply with this education requirement. All continuing education offerings must be consistent with the Board of Registration in Nursing (Board) requirements at 244 CMR 5.00: Continuing Education and, for this specific requirement, the Board Advisory Ruling #0901: Management of Pain. Advisory Ruling #0901 has been revised to include the new education requirement for APRNs with prescriptive authority.

By signing the MCSR form and by your signature on your license renewal form, you attest under penalties of perjury that you have complied with state tax and child support laws, mandatory reporting laws, and all Board laws and regulations, including continuing education requirements.

Who writes the guidelines?

  • Guidelines are developed, written and mutually agreed upon by the APRN in collaboration with a physician who is customarily accepted in the specialty area. The physician designated by the guidelines must be available to provide medical direction to the APRN as defined in the written agreement.
  • The Board does not provide a template for guidelines.

All guidelines must:

  • define the nature and scope of the APRN's practice;
  • describe the use of established procedures for the treatment of common medical conditions;
  • describe the circumstances in which physician consultation or referral is required;
  • include provisions for managing emergencies; and
  • include provisions for coverage when the specified collaborating physician is unavailable

All guidelines must contain:

  • Licensee full name as it appears on the license legibly noted with dated signature indicating collaboration in the development of the guidelines
  • Supervising physician full name as it appears on the license legibly noted with dated signature indicating collaboration in the development of the guidelines

In addition, APRN with prescriptive authority guidelines must:

  • include protocols for initiation of intravenous therapies
  • specify the frequency (not to exceed every three months) and documentation mechanism to review initial non-Schedule II prescriptions
  • specify the documentation mechanism for review of initial Schedule II prescriptions within 96 hours of issue
  • conform to M.G.L. c. 94C and regulations of the Department of Public Health at 105 CMR 700.000 et seq., and M.G.L. c. 112, §§ 80E, 80G or 80H, as applicable

Is there an audit tool to assist in determining that all the required information is included in the guidelines?

Yes, the Board's web site contains an Audit Tool for Compliance with the Regulations at 244 CMR 4.00 pdf format of Audit Tool for Compliance with the Regs @ 244 CMR 4.00 that the Board uses when guidelines are submitted for review. Others are welcome to use it to ensure guidelines contain required elements.

Who should approve the guidelines?

Guidelines must be approved by the Nursing and Medical leadership of an institution. If the APN is employed in a setting where there is no nursing and medical leadership, then the original, signed and dated practice and prescriptive guidelines must be submitted to the Board for audit and approval of compliance with the regulations at 244 CMR 4.00.

In order to approve guidelines, the following information must be verified:

  • APRN Board authorization as current and unencumbered
  • supervising physician as Board-certified and/or has admitting privileges in the APRN's area of practice
  • institutional approval or Board approval

Do guidelines have to be renewed?

Yes, guidelines must be reviewed and updated if necessary with dated signatures of both the APRN and the supervising physician every two (2) years. Guidelines must be approved by the Nursing and Medical leadership of an institution or the Board on the same schedule.

If my supervising physician changes, do I have to create new guidelines?

If the supervising physician changes prior to the end of the two (2) year approval period, the guidelines DO NOT need to be re-submitted to the Board of Nursing for re-approval. The new supervising physician must review and sign the existing guidelines or the APRN and physician can agree to create a new document. New documents would require approval as described above.

When the supervising physician changes, APRN's with prescriptive authority are required to notify the Massachusetts Department of Public Health - Drug Control Program and amend the registration. The form can be found at www.mass.gov/dph/dcp. Questions can be referred to (617) 983 - 6700, or write:
Controlled Substances Registration
305 South Street
Jamaica Plain, MA 02130

When the supervising physician changes, contact the Registration Unit of the Drug Enforcement Administration (DEA), New England Field Division at: 1-888-272-5174 or www.deadiversion.usdoj.gov to amend the Federal registration for controlled substances if the change includes name, address, Schedule, and/or drug code changes.


This information is provided by the Division of Health Professions Licensure within the Department of Public Health.