The Wisconsin Board of Nursing ("BON") recently approved revisions to Wisconsin Administrative Code N 8 ("N 8"), the regulations governing advanced practice nurse prescribers ("APNPs") in Wisconsin. An APNP is a nurse practitioner, nurse-midwife, certified registered nurse anesthetist or clinical nurse specialist who has been granted a certificate by the BON to issue prescription orders.

The BON created N 8 in 1995 after the legislature, in 1993 Wis. Act 138, authorized the BON to allow advanced practice nurses who meet certain education, training and examination requirements to issue prescription orders. The recently approved revisions are the first comprehensive updates to the initial rule. According to the BON, the changes to N 8 are intended to provide clarity and updates that reflect the current procedures and practices of APNPs. The revisions to N 8 are expected to be published in the Wisconsin Administrative Register in August or September 2016, with an effective date either September 1 or October 1, 2016. The Wisconsin Administrative Register is available here.

Summary of the Revisions

Orders for Treatment, Therapeutics and Testing. Prior to the revisions, in addition to issuing prescription orders, APNPs have been expressly permitted to issue orders for laboratory testing, radiographs or electrocardiograms appropriate to the APNP's area of competence, established by his or her education, training or experience. The revised rule states an APNP, in addition to issuing prescription orders, may issue orders for treatment, therapeutics and testing appropriate to his or her area of competence based upon his or her education, training or experience for the purpose of providing care management.

Authority to Dispense. The revised rule allows an APNP to dispense drugs to a patient at the treatment facility where the patient is treated. Prior to the revisions, APNPs have been permitted to dispense drugs to patients only if the treatment facility is located at least 30 miles from the nearest pharmacy.

Certification Renewal. The revised rule lists the requirements for an APNP to renew a certification to issue prescription orders, including that the APNP must pay renewal fees, complete a nursing workforce survey, certify completion of continuing education requirements and provide evidence of current certification by an approved certifying body as a nurse practitioner, certified nurse-midwife, certified registered nurse anesthetist or clinical nurse specialist.

Continuing Education. The revised rule requires APNPs to complete 16 hours per biennium, rather than the original rule's 8 hours per year, of continuing education in clinical pharmacology or therapeutics related to the APNP's area of practice. The BON is requiring that 2 of the 16 continuing education hours be in responsible prescribing of controlled substances. The BON states that this new requirement is in response to the current public health crisis related to prescription drug addiction.

Clarification that Prescribing Limitation Does Not Apply to Treatment of ADHD. The rule prohibits an APNP from prescribing, dispensing or administering any amphetamine, sympathomimetic amine drug or compound designated as a schedule II controlled substance to any person. The rule lists several exceptions to this prohibition, including prescribing, dispensing or administering the drug for the treatment of hyperkinesis. In the revised rule, the BON clarifies that the treatment of hyperkinesis includes the treatment of attention deficient hyperactivity disorder.

Evidence for APNP Certification to Be Provided upon Request. The revised rule requires an APNP who issues an order for a prescribed drug to be administered by a registered or licensed practical nurse to provide, upon request, to the nurse or facility where the nurse will administer the drug evidence that the APNP is properly certified to issue prescription orders. The updated language clarifies a long-standing provision.

Electronic Submission of Prescription Orders for Controlled Substances. Under the revised rule, an APNP's orders for controlled substances may be written in ink or indelible pencil or submitted electronically as permitted by state and federal law. The orders must contain the APNP's drug enforcement agency registration number. The BON updated the outdated language by removing a reference to typewritten orders and recognizing electronic submission.

Collaborative Relationship Scope and Documentation. The rule continues to require an APNP to work in a collaborative relationship with a physician. The BON, however, modified the rule to state that the health care services delivered by the APNP and physician must be within the scope of the practitioner's "training, education, and experience" rather than the practitioner's "professional experience." Also, the revised rule requires the APNP, rather than both the APNP and physician, to document the collaborative relationship. The BON stated that it removed the joint documentation requirement because the BON does not have jurisdiction over physicians.

Practical Takeaways

The revised rule explicitly allows APNPs in Wisconsin to order treatment, therapeutics and testing appropriate to the APNP's area of competence as established by the APNP's education, training or experience. The revised rule also provides APNPs with greater authority to dispense drugs within the treatment facility. APNPs who will change their current practices to issue additional types of orders or dispense drugs at the treatment facility should review and update their agreements with collaborating physicians and document any changes agreed to by the APNP and physician. An APNP who changes his or her practices also should review his or her medical liability insurance policy to ensure any change in practice is covered by the policy.

Hospitals that employ APNPs should ask their credentialing committee to determine if the credentials of the APNPs who practice in the hospital need to be updated. Hospitals also should review their policies and procedures to ensure the documents are consistent with APNP practices in the hospital, the Medicare Conditions of Participation and any other applicable state or federal law.

A copy of all of the revisions to N 8 is available here.