Nurse Practitioner Scope of Practice: Missouri

The State of Missouri is a hotbed when it comes to nurse practitioner rights.   Since the devastating tornados in Joplin, Missouri in 2011, nursing organizations have been fighting to increase nurse practitioner scope of practice.  Their argument?  NPs would have provided valuable assistance to tornado victims had their legal rights been more permissive.  Despite their cries, legislators in Missouri have been hesitant to expand the role of nurse practitioners making Missouri one of the most restrictive states for NP practice.

In what ways does the Show Me State limit the role of nurse practitioners?  Let’s take a look at the specifics.

Missouri’s Nurse Practitioner Supervision Laws

Missouri’s strict supervision laws significantly limit the scope of practice of nurse practitioners in this state.  Nurse practitioners practicing in Missouri must work under a collaborative practice agreement with a physician.  Upon entering this practice agreement, the NP must practice on site with the collaborating physician for a minimum of 30 days.  Following this 30 day period, the nurse practitioner must practice within a 30 mile radius of the collaborating physician in a non-HPSA (Health Professional Shortage Area) and within a 50 mile radius of the collaborating physician in a HPSA designated area.

Even if the nurse practitioner has extensive practice experience, upon changing collaborating physicians, the NP must again work at the same site as the new collaborating physician for a period of one month.  Following this one month period, the collaborating physician must be present on site with the NP at least once every two weeks to review the nurse practitioner’s services.  The collaborating physician must sign at least ten percent of the nurse practitioner’s charts overall, including at least twenty percent of charts in which the patient was prescribed controlled substances.  Charts must me submitted to the MD for review at least once every two weeks.  Physicians are allowed to collaborate with no more than three nurse practitioners at one time.

Nurse practitioner practice is further limited in Missouri as state law requires that any patient evaluated and treated by an NP that does not have a “self-limited or well-defined condition” be reevaluated by a physician within two weeks.  The collaborating physician must be available to the nurse practitioner at all times.  If the collaborating physician is unavailable, a designated substitute must be named and available for consultation.

Missouri’s Nurse Practitioner Prescribing Laws

Similarly to Missouri’s NP supervision laws, prescriptive privileges for nurse practitioners practicing in Missouri are restrictive.  Nurse practitioners practicing in Missouri are not allowed to prescribe controlled medications unless specifically outlined in a collaborative practice agreement with a physician.

Even if this prescriptive authority is outlined in a collaborative practice agreement, nurse practitioners are not allowed to prescribe Schedule II medications.  When prescribing Schedule III opiate and/or narcotic medications, nurse practitioners may prescribe no more than a 120 hour (5 day) supply of these drugs.  After a five day period, the nurse practitioner is allowed to generate a new prescription for the medication however the medication may not be automatically refilled.  All prescriptions must contain both the name of the prescribing NP and collaborating MD.

Other Scope of Practice Laws in Missouri

Keeping with restrictive state law, nurse practitioners in Missouri are not allowed to sign death certificates.  They are, however allowed to sign handicap parking permits.

With Missouri’s strict rules and regulations surrounding NPs, it’s no wonder publications like the Pearson Report gives the state an “F” for it’s policies regarding nurse practitioners.  With physician organizations in Missouri adamantly opposed to expanding nurse practitioner scope of practice and the rest of the nation trending towards increasing the rights of NPs, conflict surrounding nurse practitioner rights in Missouri promises to persist over the next few years.


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