A Delicate Balancing Act: The Supervision of Nurse Practitioners by Physicians

By Healthcare Attorney Alex Scarbrough Fisher

The supervision of nurse practitioners by physicians, in states that require such supervision, is often a delicate balancing act between responsibility on both the supervising MD and the NP. In order to fully illustrate this delicate balance, I will look at the specific requirements for  nurse practitioners and physicians in Tennessee.

If you live in a state that requires you as a nurse practitioner to have a supervising physician, I highly recommend reviewing the rules that govern you, as well as the rules and regulations that govern your supervising physician. Understanding what is required of each party will lead to clarity for both individuals, and hopefully a more enjoyable work environment, as well as a safer environment for your patients.

Requirements of Nurse Practitioners

In Tennessee, for example, nurse practitioners are required to keep a record of their current supervising physician with the Board of Nursing at all times. This record is commonly referred to as a “Notice and Formulary”, and must be filed within 30 days of any changes in supervising physician. This document includes notice to the Board of Nursing of who your supervising physician is, as well as a copy of the formulary describing what legend drugs you, the nurse practitioner, has permission to prescribe.

The notice and formulary is viewed as a contract between the nurse practitioner and the supervising physician authorizing what the nurse practitioner is permitted to prescribe, and who is supervising that prescribing. The Board of Nursing views the filing of the Notice and Formulary as the NP’s responsibility. As such, the Board won’t accept “I gave the notice and formulary to my supervising physician and he must have forgotten to mail it in” as an acceptable excuse to not having one on file. I recommend that all nurse practitioners ensure that they have a current notice and formulary on file by mailing in the notice themselves rather than relying on a staff member or their supervising physician to do so. The full Rules for Nurse Practitioners in Tennessee can be found here.

Requirements of Supervising Physicians

Supervising physicians in Tennessee are required to develop joint protocols between the supervising MD and the NP outlining the acceptable standard of care for patients to be treated and which drugs are appropriate to prescribe. These joint protocols should be dated and signed by the MD and NP, and should be maintained at their practice site. The supervising physicians is responsible for ensuring compliance with these joint protocols.

Supervising physicians in Tennessee are also responsible for reviewing 20% of all the nurse practitioner’s patient charts, and 100% of the NP’s charts when a controlled drug has been prescribed. This review should take place at a minimum of every 30 days. The full Rules for Supervision of a Nurse Practitioner in Tennessee can be found here.

Developing joint protocols with your supervising physician, and having him or her review 20% of your patient charts and 100% of charts where a controlled substance is prescribed allows for an extra level of protection for both NPs and patients. This provides a second set of eyes on a patient chart for an NP who may be unsure regarding their diagnosis, or who might even get audited by the Department of Health at some point during his or her career.

Joint protocols provide clarity for the NP and supervising MD as to standard of care and the appropriate way to handle patients in different situations. Although developing joint protocols and reviewing patient charts is the responsibility of the supervising MD, it benefits the NP to make current and future supervising physicians aware of these requirements if they are not already. For those nurse practitioners outside of Tennessee, reviewing your state’s applicable rules for you as a nurse practitioner is highly recommended to ensure success in your next supervising physician relationship.


Alex Scarbrough Fisher  is an associate attorney at Frost Brown Todd, LLC. Her practice area focuses on litigation and administrative law. Alex’s administrative law practice’s emphasis is in health care related boards, including the Tennessee Board of Medical Examiners and the Tennessee Board of Nursing.


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