Legal requirements for supervising non-physician clinicians
Working responsibly with nurse practitioners (NPs) and physician assistants (PAs) requires an understanding of local regulations.
Overview of supervision and collaboration in family medicine
Non-physician clinicians (NPCs) can be key team members in a value-based care model. But physicians have a responsibility to ensure the NPCs they supervise provide quality care and comply with state laws. Each state defines scope of practice for NPCs and sets supervision guidelines, if applicable. Failing to understand and follow state laws and regulations can put you at risk for malpractice lawsuits and medical board investigations.
When supervising an NPC, ensure your scope of practice and their scope of practice are compatible. For example, if you are a geriatrician, it isn't advisable to supervise an NPC who will be providing mainly pediatric care in your practice or doing procedures you do not perform.
Definitions: Supervising physician, collaborative agreements
The central principle underlying physician supervision of NPCs is that the physician retains ultimate responsibility of the patient care rendered when so required by state law. In these cases, physician supervision means that the NPC only performs medical acts and procedures that have been specifically authorized by the supervising physician.
Beyond that core tenet, the AAFP’s policy guidelines lay out the following responsibilities for the supervising physician:
Assure all delegated activities are within the scope of the NPC's education, training and experience.
Continually direct and review the NPC's work, records and practice to ensure appropriate directions are given and understood and appropriate treatment is rendered.
Off-site work: The supervising physician or a designated alternate (same specialty) must be available in person or electronically any time an NPC is caring for patients.
Specifics regarding an NPC's scope of practice and how the supervising physician directs and reviews their work vary by state. Nearly all states require PAs to have some level of supervision or collaboration with a physician, while some states allow NPs and advanced practice registered nurses (APRNs) to practice independently. Specifics are spelled out in legal contracts known as collaborative agreements, which are required by some states for physicians and NPCs to work together.
State-by-state supervision requirements
State medical boards generally govern PAs, although some states have separate PA boards. For NPs and nurse midwives, the regulatory agency is the state nursing board. State boards can provide the most up-to-date policies on NPCs' scope of practice and physicians' legal responsibilities when supervising or collaborating with NPCs.
Physicians should pay particular attention to the language used in state statutes and regulations related to supervision versus collaboration with NPCs. Many states have updated their laws to reflect a transition to a collaborative working environment for physicians and NPCs. States that require supervision of NPCs will define what supervision entails at the practice level in state code and/or regulations. These regulations may address any or all of the following: physician availability, regular review, delegation of tasks and frequency of direct supervision.
While state statutes and regulations govern the scope of practice for NPCs, health systems and other employers may have additional guidelines, policies or procedures related to how NPCs practice.
In addition to the state resources below, many AAFP chapters can provide state-specific guidance for family physicians on supervising or collaborating with NPCs.
Find your state to learn more
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative practice agreement required.
State resources:
- Alabama Board of Nursing – Advanced practice
- Alabama Board of Medical Examiners and Medical Licensure Commission
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration required, including monthly contact between PA and collaborating physician.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required, including weekly meetings between PA and supervising physician.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative practice agreement required.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
- California Board of Registered Nursing
- California laws and regulations for NPs
- California nurse practitioner practice
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- NPs must practice in collaboration with a physician who is licensed in Connecticut for at least three years to gain full practice authority.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaborative relationship with the supervising physician.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Written collaborative agreement with physician required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
District resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required.
District resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- NPs must complete 3,000 practice hours under a physician’s supervision to gain full practice authority.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
Resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Written collaborative agreement with physician required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative agreement required, except for:
- APRNs who practice in a hospital, hospital affiliate or ambulatory surgical treatment center
- APRNs who are granted full practice authority
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative practice agreement required.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Written collaborative agreement with physician required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required, including a written supervisory agreement.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative agreement required for prescribing controlled substances and other specified drugs.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative practice agreement required.
State resources:
- Louisiana State Board of Nursing
- Louisiana nursing professional standards
- Louisiana guidelines for interpreting scope of practice for APRNs
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaborative agreement required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
- Massachusetts Board of Registration in Nursing
- Massachusetts nursing laws and regulations
- Massachusetts 244 CMR 4.00: Advanced practice registered nursing
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration through a written practice agreement required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- NPs must complete at least 2,080 hours within the context of a collaborative management setting to gain full practice authority.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration through a practice agreement required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative agreement required.
State resources:
- Mississippi Board of Nursing
- Mississippi statutes and regulations for APRNs
- Mississippi Board of Nursing decision-making model
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Collaborative practice agreement and physician supervision required.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Collaboration according to the terms of a written practice agreement.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required, including monthly face-to-face meetings between the PA and physician.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- NPs must complete at least 2,000 practice hours with a supervising physician under a transition-to-practice agreement to gain full practice authority.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision and collaborative agreement required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- NPs must complete at least two years or 2,000 practice hours before they can prescribe controlled substances without a collaborating physician.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required, including in-person supervision at least once a month.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Written collaboration agreement required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Joint protocol with collaborating physician required.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- PAs must practice under supervision of a physician for three years before they can transition to a collaborative relationship.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- NPs must complete at least 3,600 practice hours with a collaborating physician under a written practice agreement to gain full practice authority.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Physician supervision required, including monthly meetings between PA and physician in the first six months.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
- North Dakota Board of Nursing
- North Dakota advanced practice FAQs
- North Dakota administrative code for APRNs
PA scope and requirements
Practice environment:
- Full (State statute and/or regulation does not limit PA practice; PAs may practice to the full extent of their medical education, training and experience under collaboration with a physician. Health care teams or employers may set guidelines for collaboration.)
Physician supervision/collaboration:
- Collaboration under a written collaboration agreement is required for PAs with less than 4,000 practice hours.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Standard care arrangement with collaborating physician required.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaborative agreement required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative agreement required.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative agreement required.
Resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Written practice agreement required.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Collaboration required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
PA scope and requirements
Practice environment:
- Moderate (State statute and/or regulation includes additional administrative requirements, limiting PA flexibility in practice.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative agreement required.
Resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Full (State statute and/or regulation does not limit PA practice; PAs may practice to the full extent of their medical education, training and experience under collaboration with a physician. Health care teams or employers may set guidelines for collaboration.)
Physician supervision/collaboration:
- Collaboration required, although degree of required collaboration varies based on the number of practice hours accrued.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- NPs must complete 1,600 practice hours under a physician’s supervision to gain full practice authority.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration through practice agreement required.
State resources:
NP scope and requirements
Practice environment:
- Restricted practice authority (NPs cannot perform their scope of practice without a supervising physician. State law requires that NPs are supervised by a physician.)
Physician supervision/collaboration:
- Practice agreement required, except for NPs who have completed at least five years of clinical practice experience under a physician’s supervision.
State resources:
- Virginia Board of Nursing
- Virginia regulations for NPs
- Virginia code for licensure and practice of APRNs
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration through practice agreement required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Reduced (State statute and/or regulation limits PA practice in at least one area and requires physician supervision or limited delegated authority.)
Physician supervision/collaboration:
- Physician supervision required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative agreement required.
State resources:
- West Virginia RN Board
- West Virginia nursing statutes and regulations
- West Virginia nursing scope of practice
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration required.
State resources:
NP scope and requirements
Practice environment:
- Reduced practice authority (NPs can perform some of their scope of practice without a supervising physician; however, restrictions apply. Restrictions vary by state but may include prescribing certain medications or operating their own independent practice. As a result, NPs are often in collaborative agreements with physicians.)
Physician supervision/collaboration:
- Collaborative agreement required.
State resources:
PA scope and requirements
Practice environment:
- Advanced (State statute and/or regulation allows PAs to practice to the full extent of their medical education, training and experience, but they are subject to state administrative requirements.)
Physician supervision/collaboration:
- Collaboration through written collaborative agreement required.
State resources:
NP scope and requirements
Practice environment:
- Full practice authority (NPs can perform the full scope of practice without a supervising or collaborating physician. NPs can evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments, including prescribing medications; and operate their own independent practices.)
Physician supervision/collaboration:
- N/A – NPs can practice independently.
State resources:
PA scope and requirements
Practice environment:
- Full (State statute and/or regulation does not limit PA practice; PAs may practice to the full extent of their medical education, training and experience under collaboration with a physician. Health care teams or employers may set guidelines for collaboration.)
Physician supervision/collaboration:
- Degree of collaboration is determined at the practice level.
State resources:
Establishing collaborative and supervisory agreements
Collaborative practice agreements: Key elements
As noted above, collaborative agreements are written contracts between a physician and an NPC or other outside care provider and are required by law in several states. The structure of the agreements varies by state, but generally they cover:
Availability of the collaborating physician for patient referral and consultation
Coverage plans for emergency absence of either the NPC or the collaborating physician
Resolution of disagreements between the NPC and the collaborating physician regarding diagnosis and treatment
Periodic review by the collaborating physician of NPC patient records
Written standard protocols the NPC will follow
Documentation and compliance tips
Maintaining a complete and accurate record of collaborative activity between a physician and an NPC will help you stay in compliance with state laws and other regulations. Keep an electronic record, if possible, of the collaborative agreement itself, along with chart reviews, summaries of meetings, treatment plans, and other documents related to collaboration and patient care.
Common areas in which you may run into compliance issues include scope of practice violations, failure to provide adequate supervision and incorrect billing. Refer to the charts above for your state’s laws and policies on NPC scope of practice and supervision. In addition, see the AAFP’s guide to billing for NPC services.
FAQs for family medicine teams
What is the legal scope of practice for NPCs?
The scope of practice for NPCs is determined by state statutes and regulations. Consult state regulatory agency websites for the most up-to-date statutes, regulations and policies pertaining to NPC scope of practice. Physicians can also look to state boards for interpretative statements of regulation that can serve as guidelines for proper implementation.
Nearly all states require PAs to have some level of supervision or collaboration with a physician; however, the details of these arrangements vary by state. NPs have more variation across states in their practice authority, ranging from full practice authority with the ability to operate independent practices to restricted practice authority that requires NPs to be supervised by a physician.
While state statutes and regulations govern the scope of practice for NPCs, health systems and other employers may develop additional guidelines, policies or procedures related to how NPCs practice within that environment.
The following is a list of credible resources for understanding current scope of practice regulations by state:
- Vivian: 2023 State by state scope of practice: Physician assistant
- AMA: PA scope of practice resource
- AAPA: Guide to PA regulations and compliance (2023)
- AAPA: List of licensing boards for PAs
- AANP: Standards of practice for NPs
- AANP: Scope of practice for NPs
- AANP: Overview of state practice environment for NPs
- Nursing Process: NP scope of practice by state (2023)
How can I understand my contractual obligations for working with an NPC?
Thoroughly review your physician employment contract and ask questions about your employer’s expectations related to supervision/collaboration with NPCs. If you are employed, your employer’s expectations for supervision should be laid out in writing in your employment contract. Supervision requirements are sometimes addressed in contract addendums. These should be carefully reviewed before signing.
When specific contracting questions or concerns arise, physicians should engage with a health care attorney with experience in physician employment contracts. See the AAFP’s information on employment contracting to get tips on negotiating contracts.
Be familiar with state legal requirements. You may also look to your state medical board to understand what contract language is typical and appropriate when outlining physician supervision/collaboration responsibilities. The AAFP supports appropriate compensation for physicians’ supervision of NPCs in addition to their core compensation. See the AAFP’s policy on physician compensation for NP and PA oversight.
Considerations in your contract review:
- How many NPCs will I be expected to supervise/collaborate with?
- What are the expectations for supervision/collaboration at this organization?
- Does my contract ensure that I will have time to follow the legal responsibilities required by my state?
- Will my liability change because of my supervision of/collaboration with NPCs?
- What support (e.g., in-house legal counsel) is available to me if I have questions regarding my supervision/collaboration role?
- Am I being appropriately compensated for supervision/collaboration?
Resources:
Is there a legal or ideal limit to how many NPCs I can supervise?
In states where supervision or collaboration is required for NPCs, maximum physician-to-NPC ratios are determined at the state level through statutes and regulations or professional code. Details on state code and regulations can be found through state regulatory agency websites. These legal guidelines can serve as a starting point for conversations about how many NPCs a physician can reasonably expect to supervise.
How many NPCs should I supervise?
The precise supervision ratio that is right for one physician may not be right for another, and it will be influenced by practice size and the experience level of both the physician and the NPCs.
Consider these factors when determining how many NPCs to supervise or collaborate with:
- Outside of minimum legal requirements, will the NPC need additional training and support to provide quality patient care?
- What is the culture of the practice environment? How can you build and maintain trust with the NPC?
- How will you establish feedback loops and ongoing communication?
- How much of your time will this take?
This may be directed by the organization or health system in which the physician is employed. Employed physicians should direct their questions accordingly.
What are my responsibilities when an NPC I supervise makes a mistake?
The AAFP believes that patients should be informed about all aspects of their health care, as outlined in the AAFP’s position paper on disclosing unanticipated clinical outcomes. The Communication and Optimal Resolution (CANDOR) toolkit from the Agency for Healthcare Research and Quality is intended to help health care institutions and clinicians use a patient-centered process to communicate in a timely, thorough and just way when unexpected events cause patient harm.
Generally speaking, you should handle adverse and unwanted events involving an NPC the same way you would handle a similar situation with a physician colleague. The AAFP encourages physicians to be aware of current policies and procedures that affect their individual practice situation, including the policies of their employer, hospital, state medical board and malpractice insurance carrier. In some cases, one or more of these entities may require physicians to report incidents prior to disclosure or in addition to disclosure. You may benefit from speaking with in-house legal counsel, consulting the human resources department or the medical director, reviewing your employer’s bylaws and meeting with the head of NPCs, if the organization has one.
Failure to report may have negative consequences, including the potential for disciplinary action on the physician’s license or loss of malpractice coverage. Physicians should also be aware that resignation of clinical privileges during an investigation is reportable to the National Practitioner Data Bank.
What do I do if I believe an NPC I work with is cognitively impaired?
Approach a situation in which you believe an NPC is cognitively impaired by following guidelines that would be utilized for a physician colleague. Consider contacting your state physician health program (PHP). The Federation of State Physician Health Programs has contacts for each state’s program (with the exception of Maine, Nebraska and Wisconsin). PHPs are confidential resources for physicians, other licensed health care professionals and those in training who have addictive, psychiatric, medical, behavioral or other potentially impairing conditions. These programs coordinate evaluation, treatment and continuing care of clinicians with these conditions. Most state websites contain FAQs that may help you determine appropriate action. They also allow for anonymous notification of suspected impairment of licensed clinicians.
In addition, review your organizational or institutional policies for required actions. Consult in-house legal counsel, the human resources department or the medical director, if necessary.
How can I learn about legal cases or disciplinary actions involving NPCs?
As you consider hiring an NPC or are assigned to supervise a new NPC, you may want to understand their past legal, malpractice or licensure issues. Any concluded legal investigation, licensure disputes or disciplinary actions for clinicians are recorded by the state licensing boards associated with their license. Contact state boards to get information on individual clinicians. In addition to state boards, the National Practitioner Data Bank and the Office of Inspector General’s list of excluded individuals/entities provide information on medical malpractice payments and adverse action reports against clinicians.
In large health systems, a credentialing committee often handles this process. In a smaller practice environment, there should be a hiring policy in place that outlines the process for identifying any medical or legal cases in which candidates have been involved.