What You Need to Know if You Need a Supervising Physician

Earlier this year, we wrote about Virginia’s new law eliminating the direct supervision requirement and allowing for autonomous practice (a.k.a. independent practice) for qualifying Nurse Practitioners (NPs). We expect the application process for qualifying NPs who wish to open an autonomous practice to open later this year, and will update The Latest as soon as new information is released.

But what about NPs who don’t yet qualify or who do not have an interest in practicing autonomously? In Virginia (and in many other states), NPs who do not have an autonomous practice must practice under the direct supervision of a physician as part of a patient care team, pursuant to what is called a “Practice Agreement,” or, “Collaborative Practice Agreement.” A Practice Agreement is an agreement between an NP and the NP’s supervising physician that describes the relationship between the parties, including the procedures to be followed and acts to be performed by the NP in the course of providing care to patients.

In Virginia, a Practice Agreement must include, without limitation, the following provisions (see Joint Board Guidance Document 90-56):

  1. A description of the NP’s scope of practice and the setting or settings in which the NP is actively practicing;

  2. Provisions for the periodic review of patient records by the supervising physician;

  3. Provisions for particular situations that require input by the supervising physician;

  4. Provisions for what the NP should do in case of a patient emergency and when a referral should be made;

  5. Categories of drugs and devices the NP may prescribe;

  6. Guidelines for the availability and ongoing communication between the NP and the supervising physician;

  7. A provision for periodic joint evaluation of the services being provided and of patient outcomes;

  8. A provision for the periodic review and revision of the practice agreement; and

  9. Signature of both parties.

Though not required, the following are some examples of additional provisions to include in a Collaborative Practice Agreement in Virginia:

1. A backup clause. Identify a secondary or back-up physician for the NP to contact in the event that the primary supervising physician cannot be reached.

2. Specific authorizations. It is sometimes a good idea to address specific tasks the NP will be authorized to perform that would normally be considered outside the NP’s scope of practice. For example, the physician can authorize the NP to write prescriptions for controlled substances, write DNR orders, and refer patients for physical therapy. Including these specific authorizations clarifies the relationship between the NP and the physician and eliminates ambiguity as far as what the NP is authorized to do.

3. Exceptions. In some cases, the physician and/or NP may want to enumerate specific tasks the NP will not be allowed to perform. For instance, if the physician does not want to delegate full prescriptive authority to the NP, the agreement should list the drugs and/or devices the NP will not be allowed to prescribe, or limit the NP’s prescriptive authority to that assigned to the NP by the DEA. Including such exceptions limits both parties’ risk by preventing the NP from performing tasks he or she should not perform.

4. Resolution of Disagreements. It is important to include procedures to be followed in the event of a disagreement between the NP and supervising physician regarding a patient’s care that falls within both parties’ scope of practice. Typically, a Practice Agreement will require the parties to consult current medical and nursing peer literature to attempt to come to a consensus before ultimately allowing the supervising physician’s opinion to prevail.


Nixon Law Group attorneys have extensive experience drafting Practice Agreements between NPs and supervising physicians, and we are happy to assist you in drafting yours. Contact us to learn more.


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