Ohio Nurse Practice Act: 1 Hour Category A

In Ohio, Registered Nurses (RNs) are expected to provide nursing care in a manner defined by the Board of Nursing, as stipulated within the NPA. What is expected, at a minimum, is composed of the following (ORC, 4723.01 (B)-(D)), (OAC, 4723-4-03):

• Maintenance of current knowledge in the areas of duties, responsibilities and accountabilities required for safe nursing practice.
• The ability to demonstrate both competence and accountability in all of the areas of practice in which that nurse is engaged. This includes, but is not limited to the following;
  • Consistent performance in all aspects of nursing care.
  • The ability to assess health status for the purpose of providing nursing care.
  • Health counseling and teaching abilities.
  • Skills for safe administration of medications, treatments, executing regimens appropriate for a nurse's professional practice.
  • The ability to teach, administer, supervise, delegate and evaluate nursing practice.
  • The ability to recognize and intervene appropriately when a complication arises, as well as the ability to refer or consult when needed.

Duties that registered nurses are expected to complete within a "timely manner" include the following:

• Implementation of any order for a client unless the registered nurse believes or should have reason to believe the order is;
  • Inaccurate
  • Not properly authorized
  • Not current or valid
  • Harmful or potentially harmful to that client
  • Contraindicated by other documented information
• Clarify any order for a client when the registered nurse believes or should have reason to believe the order is;
  • Inaccurate
  • Not properly authorized
  • Not current or valid
  • Harmful or potentially harmful to that client
  • Contraindicated by other documented information

When it is necessary to clarify an order the registered nurse is expected to (in a timely manner) consult with an appropriate licensed practitioner. If a decision is made not to follow the direction or administer the medication or treatment as ordered it is up to the registered nurse to notify the prescribing practitioner (again in a timely manner) and document the notification along with the reason for not following the order. The most important thing however is the mandate to take actions as needed to assure the safety of the client.

The NPA requires a registered nurse to report or consult whenever necessary with other members of the health care team, as well as make referrals if that seems appropriate. While doing so, care must be taken to maintain client confidentiality and limit the communication of nonessential information to other health professionals as much as possible. What would be optimal is to involve the client by allowing consent decisions regarding what information may be communicated to others. This includes the use of written consent permissions in all circumstances appropriate for their use.

It is expected that registered nurses practicing in Ohio maintain acceptable standards of safe nursing care in the areas of observation, advice, instruction, teaching, or evaluation. They are also expected to communicate information in an acceptable manner within the standards of safe nursing care. This includes identifying their title to the person with whom they are communicating.

When providing direction to a licensed practical nurse, it is up to the registered nurse to first assess:

• The condition of the client, including their stability
• The type of nursing care required by the client
• The complexity and frequency of any nursing care needed
• The training, skill and ability of that licensed practical nurse in relation to their ability to perform specific needed functions or procedures
• The availability and accessibility of resources needed in order to safely perform the specified function or procedure

The eternal question "Vocational vs. Practical" is answered by the Ohio NPA. In Ohio, the title is LPN Licensed Practical Nurse.

The practice of nursing as a licensed practical nurse" means providing to individuals and groups nursing care requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences at the direction of a registered nurse or any of the following who is authorized to practice in this state: a physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor (ORC 4723.01(6)(f).

The Standards of Practice for a Licensed Practical Nurse is the LPN is expected to function within the limits of practice set out by the Ohio Revised Code as well as by any rules by the Board of Nursing, applicable laws, rules and professional standards (ORC, 4723.01(E)-(F)), (OAC, 4723-4-04):

It is an expectation that current knowledge of duties, responsibilities and accountabilities necessary for safe nursing practice be maintained, and that a licensed practical nurse is able to demonstrate competence and accountability in the care that they deliver. Licensed Practical Nurses are also expected to possess the skills necessary to recognize, refer, seek consultation or implement interventions that may be needed to handle complications which may arise.

In the state of Ohio, it is expected that a licensed practical nurse will, in a timely manner, complete the following:

• Implement any order or direction for a client unless the licensed practical nurse believes or should have reason to believe the order is;
  • Inaccurate
  • Not properly authorized
  • Not current or valid
  • Contraindicated by other documented information
• Obtain clarification for any order or direction for a client when the licensed practical nurse believes or should have reason to believe the order or direction is;
  • Inaccurate
  • Not properly authorized
  • Not current or valid
  • Contraindicated by other documented information

Clarification for an order or direction requires a timely consultation with an appropriate licensed practitioner and notification of the prescribing practitioner should the licensed practical nurse decide not to follow the direction or administer the medication or treatment as prescribed. This must be followed with documentation that the practitioner was notified of the decision as well as the reason for that decision. Above all, the licensed practical nurse is expected to act when needed to assure the safety of the client.

A licensed practical nurse is expected to report to and consult with other nurses or members of the health care team in a timely manner. They are also expected to make referrals for the client as appropriate. When discussing client information with other health providers the licensed practical nurse must maintain client confidentiality to the greatest extent possible. As much as possible it is desired that the client has the right to give or withhold consent regarding the release of information. This includes the use of written consents when appropriate or in all circumstances identified by law.

In those instances, in which a licensed practical nurse is directed to observe, advise, instruct, or evaluate the performance of a nursing task they are expected to use acceptable standards of safe nursing care as a basis. Any information they communicate should be within the acceptable standards of safe nursing care.

Licensed Practical Nurses (LPNs) in Ohio may be eligible for Intravenous Therapy privileges after licensure in the state (ORC, 4723.18), (OAC, 4723-18), If this is desired they must demonstrate successful completion of a Board approved course of study in the safe performance of Intravenous Therapy. The laws for IV therapy by LPNs are very specific.

When a licensed practical nurse authorized by the board to perform intravenous therapy performs an intravenous therapy procedure at the direction of a registered nurse, the registered nurse or another registered nurse shall be readily available at the site where the intravenous therapy is performed, and before the licensed practical nurse initiates the intravenous therapy, the registered nurse shall personally perform an on-site assessment of the adult patient who is to receive the intravenous therapy. (OAC, 4723-18 (2)(C)(1)).

The nursing process and dedicated nurses have been shown to be valuable in every area of health care. The state of Ohio in its NPA recognizes that nurses can be found everywhere, doing many different tasks at all levels of care. For that reason, it has specifically addressed the standards it expects from Advance Practice Nurses (APRN) (ORC, 4723.01(G)-(J)), (OAC, 4723-4-05):

• Certified Nurse Midwife
• Certified Nurse Practitioner
• Certified Registered Nurse Anesthetist
• Clinical Nurse Specialist

4723-8-04 Standard care arrangement for a certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist.

Before beginning practice, a standard care arrangement shall be entered into with each physician or podiatrist with whom the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist collaborates. The standard care arrangement can be revised to add or delete a physician or podiatrist within that employment setting instead of making a new arrangement. A new standard care arrangement is needed when the nurse is employed at a different setting and engages in practice with different collaborators. The collaborating physicians or podiatrists practice must be the same or similar to the nurse's practice.

A clinical nurse specialist without a certificate to prescribe whose nursing specialty is mental health or psychiatric mental health is not required to enter into a standard care arrangement.

A standard care arrangement includes at least:

signatures of each nurse, and each collaborator, indicating review of and agreement to abide by the terms of the standard care arrangement.

The date when the arrangement is initially executed

The date of the most recent review of the arrangement

The complete name, specialty and practice area, business address, and business phone number or number at which the individual can be reached at any time for all participants.

A statement of services offered by the nurse or holders of a certificate to prescribe, including a description of the scope of prescriptive practice.

A plan for incorporation of new technology or procedures.

Quality assurance provisions:

1. Review and reapproval of the standard care arrangement every two years. Criteria for referral of a patient by the nurse to a collaborating physician or podiatrist.
2. A process for the nurse to obtain consultation from a physician or podiatrist;
3. A procedure for regular review of referrals made by the nurse.
4. A process for chart review if the nurse's practice includes any direct patient care, education, or management.
5. A policy for care of infants up to age one and recommendations for collaborating physician visits for children from birth to age three, if the nurse is providing services to infants.
6. A plan for coverage of patients in instances of emergency or planned absences of the nurse or collaborators.
7. A process for resolution of disagreements regarding matters of patient management
8. An arrangement regarding reimbursement under the medical assistance program
9. For nurses with a current valid certificate to prescribe, the following quality assurance provisions shall include at least:
10. Provisions to ensure timely direct, personal evaluation of the patient with a collaborating physician or the physician's designee when indicated
11. Additional prescribing parameters for those drugs or therapeutic devices established in the formulary, including provisions for use of:
    1. drugs with non-food and drug administration (FDA) approved indications
    2. drugs approved by the FDA and reviewed by the committee on prescriptive governance subsequent to the date of the standard care arrangement
    3. drugs previously reviewed by the committee on prescriptive governance but approved by the FDA for new indications subsequent to the date of the standard care arrangement
    4. schedule II controlled substances.
    5. opioid analgesic to a minor if prescribing to minors.
    6. for obtaining and reviewing OARRS reports, and engaging in physician consultation and patient care consistent.
    7. a quality assurance committee periodic review, at least semiannually, of:
       1. A representative sample of prescriptions written by the nurse;
       2. A representative sample of schedule II prescriptions written by the nurse
    8. ensure that the nurse is meeting all the requirements of rule 4723-9-12 of the Administrative Code related to review of a patient's OARRS report, consultation with the collaborating physician prior to prescribing based on the OARRS report and signs of drug abuse or diversion as set forth in rule 4723-9-12 of the Administrative Code, and documentation of receipt and assessment of OARRS report information in the patient's record.

The most current copy of the standard care arrangement, and any legal authorization signed by a physician must be available upon request at each site where practice of the occurs. Upon request of the board, the nurse must provide a copy of the standard care arrangement to the board. Retain copies of previously effective standard care arrangements for three years.

When a hospital negotiates a standard care arrangement the review and approval of the standard care arrangement must be in accordance with the policies and procedures of the hospital governing body and the bylaws, policies, and procedures of the hospital medical staff.

A nurse must notify the board of the identity of a collaborating physician or podiatrist any change in the name and business address of a collaborating physician or podiatrist within 30 days.

A clinical nurse specialist who does not hold a certificate to prescribe and whose nursing specialty is mental health or psychiatric mental health shall identify one or more physicians with whom they collaborate, but a standard care agreement is not required.

An APN may practice without a collaborating physician or podiatrist for notmore than 120 days if the physician or podiatrist terminates the collaboration beforethe standard care arrangement expires.

Certified Nurse Midwives are now authorized to treat their female patients’ male partners only to the extent of issuing or providing the prescription or the drug to treat chlamydia, gonorrhea, or trichomoniasis and to provide the related health care information as provided in Section 4723.4810, ORC.

An advanced practice registered nurse may delegate the administration of medication to an unlicensed person

HB 341 imposes legal requirements for CTP holders. CTP holders who hold appropriate DEA certification and prescribe opioid analgesics or benzodiazepines. Before initially prescribing or personally furnishing an opioid analgesic or a benzodiazepine, The APRN must request patient information from OARRS that covers at least the previous 12 months, and make periodic requests for patient information from OARRS if the course of treatment continues for more than 90 days. Exceptions to the requirement to check OARRS under these circumstances include drugs prescribed to hospice or cancer patients, drugs to be administered in hospitals or long-term facilities, drugs to treat acute pain from surgery or a delivery, and drug amounts for use in seven days or less.

The law further requires the Nursing Board to verify that licensees prescribing in this manner are registered and using OARRS appropriately. Violations of these legal requirements may subject licensees to discipline (OBN Momentum, winter 2015).

APRNs with prescriptive authority may delegate to a person not otherwise authorized to administer drugs, the authority to administer drugs to a specified patient. Prior to delegating this authority, the CTP holder is required to assess the patient, determine that the drug is appropriate for the patient, and determine that the person to whom the authority will be delegated has met the conditions Section 4723.489, ORC. For example, a CTP holder is limited to delegating only the administration of drugs that the CTP holder may prescribe him/herself, and the CTP holder is prohibited from delegating the administration of intravenous drugs and controlled substances. There are also restrictions on the locations where the authority to administer drugs may be delegated by a CTP holder. Section 4723.489(C), ORC, prohibits the delegation from occurring in hospital inpatient care units, hospital emergency departments, freestanding emergency departments, or ambulatory surgery facilities. The CTP holder must be physically present at all locations where a drug is administered through CTP holder delegation. Prior to delegating, the CTP holder must determine that the individual who will administer the drugs has successfully completed drug administration education based upon a recognized body of knowledge, and that the individual has demonstrated to their employer the knowledge, skills, and ability to safely administer the drug(s). All of this must be documented and made available to the delegating CTP holder to determine whether the delegation is appropriate for patient safety and well-being. (OBN Momentum, fall 2015).

4723-9-10 Formulary; standards of prescribing for advanced practice registered nurses designated as clinical nurse specialists, certified nurse-midwives, or certified nurse practitioners.

The Board adopted an exclusionary formulary, based upon the recommendation of the Committee on Prescriptive Governance (CPG). The exclusionary formulary speci?es that CNSs, CNPs and CNMs shall not prescribe any drug in violation of federal or Ohio law. It further states that the prescriptive authority of a CNS, CNP and CNM shall not exceed the prescriptive authority of the collaborating physician or podiatrist. The exclusionary formulary is on the Board website at www.nursing.ohio.gov/Practice-Prescribing.htm.

Sections 4723.431(E) and 4731.27, ORC

Morphine equivalent daily dose (MED) means a conversion of various opioid analgesics to a morphine equivalent dose by the use of accepted conversion tables provided by the state board of pharmacy at: www.ohiopmp.gov/MED_Calculator.aspx.

A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may;prescribe any drug or therapeutic device in any form or route of administration if:

1. The ability to prescribe the drug or therapeutic device is within the scope of
2. practice in the nurse's specialty area
3. The prescription is consistent with the terms of a standard care arrangement
4. The prescription would not exceed the prescriptive authority of the collaborating
5. physician
6. The individual drug or subtype or therapeutic device is not one excluded by the
7. Formulary
8. The prescription meets the requirements of state and federal law
9. A valid prescriber-patient relationship exists. This relationship may include, but is not limited to:
   1. Obtaining a thorough relevant history of the patient;
   2. Conducting a physical or mental examination of the patient;
   3. Rendering a diagnosis
   4. Prescribing medication, ruling out the existence of any recognized contraindications
   5. Consulting with the collaborating physician when necessary
   6. Documenting these steps in the patient's medical records

A nurse may prescribe or personally furnish a drug to not more than a total of two individuals who are sexual partners of the nurse's patient. If the patient is a family member, acceptable and prevailing standards of safe nursing care require that a nurse maintain detached professional judgment. The nurse shall not prescribe to a family member unless:

1. The nurse is able to exercise detached professional judgment in reaching diagnostic or therapeutic decisions
2. The prescription is documented in the patient's records

For drugs that are a controlled substance:

1. The prescription indicates the ICD-10-CM medical diagnosis code of the
2. primary disease or condition that the controlled substance is being used
3. to treat.
4. The prescription indicates the intended days' supply of the controlled
5. substance prescription. The intended days' supply is calculated by
6. dividing the total quantity prescribed by the maximum intended number
7. of tablets or doses per day;
8. The patient is not a family member; and
9. The nurse shall not self-prescribe a controlled substance

A schedule II controlled substance can only be prescribed in situations where all of the following apply:

1. A patient has a terminal condition;
2. A physician initially prescribed the substance for the patient; and
3. The prescription is for a quantity that does not exceed the amount necessary for the patient's use in a single, seventy-two hour period
4. The patient is in one of the following settings:
   1. hospital
   2. entity owned or controlled, in whole or in part, by a hospital
   3. health care facility
   4. nursing home
   5. county home or district home
   6. hospice care program;
   7. community mental health agency
   8. ambulatory surgical facility
   1. freestanding birthing center
   10. federally qualified health center
   11. federally qualified health center look-alike,
   50. health care office or facility operated by the board of health of a city or general
   1000. health district
   14. site where a medical practice is operated, but only if the practice is comprised of one or more physicians who also are owners of the practice; the practice is organized to provide direct patient care
   15. residential care facility

a schedule II controlled substance cannot be prescribed from a convenience care clinic even if the clinic is owned or operated by one of the above entities. Extended-release or long-acting opioid analgesics shall not be prescribed for thetreatment of acute pain.

Before prescribing an opioid analgesic, the nurse shall first consider nonopioidtreatment options. If opioid analgesic medications are required asdetermined by history and physical examination, the prescription should be forthe minimum quantity and potency needed to treat the expected duration ofpain, with a presumption that a three-day supply or less is frequently sufficient. For adults, not more than a seven-day supply with no refills; for minors, not more than a five-day supply with no refills. The seven-day limit for adults and five-day limit for minors may be exceeded for pain that is expected to persist for longer than sevendays based on the pathology causing the pain. In this circumstance, the reason that the limits are being exceeded and the reason that a non-opioid analgesic medication was not appropriate to treat the patient's condition shall be documented in the patient's medical record.

The total morphine equivalent dose (MED) of a prescription for opioid

analgesics for treatment of acute pain shall not exceed an average of thirty

MED per day. To exceed this MED of thirty, the patient's treating physician has entered a standard care arrangement with the advanced practice registered nurse that states the understanding of the physician as to when the nurse may exceed the thirty MED average, and when the nurse must consult with the physician prior to exceeding the thirty MED average.

The prescription guidelines for acute pain do not apply when an opioid analgesic is prescribed:

1. To an individual who is a hospice patient or in a hospice care program;
2. To an individual who is receiving palliative care;
3. To an individual who has been diagnosed with a terminal condition; or
4. To an individual who has cancer, or a condition associated with the individual's cancer or history of cancer.
5. for the treatment of opioid addiction utilizing a controlled substance

Drugs approved by the FDA but not yet reviewed and approved by the committeeon prescriptive governance may be prescribed, unless later disapproved by the

committee on prescriptive governance, if:

1. The drug type or subtype is not excluded on the formulary,
2. The collaborating physician has agreed in the standard care arrangement that the nurse may prescribe drugs approved by the FDA, that have not yet been reviewed and approved by the committee on prescriptive governance.

An APRN shall not prescribe any drug or device to perform or induce an abortion.

The APRN may prescribe or personally furnish naloxone.