On the Job, Scope of Practice

Scope of Practice With Nurse Practitioners

I have been receiving an increasing number of questions about the scope of practice for medical assistants when they are working under the supervision of nurse practitioners (NPs) or physician assistants (PAs), and not under the direct supervision of a physician. This scenario will become more frequent because of the Affordable Care Act and the anticipated increase in demand for primary care, which is often provided by NPs and PAs.

Because physician assistants always work under physician authority and supervision—although, in some states, very general physician supervision—the scope of practice for medical assistants working under PAs is usually very similar to their scope of practice when working under physician supervision. However, there are some state laws that do not permit medical assistants to administer medication unless a physician (MD) or osteopath (DO) is on the premises.

Medical assistants’ scope of practice when working under nurse practitioners (or other advanced practice nurses) is usually more difficult to ascertain from state law. The controlling law is the state nurse practice act and the regulations and policies of the state board of nursing. Often, the legal analysis is complicated.

If you work under the direct supervision of a nurse practitioner or a physician assistant and have questions about scope of practice, please feel free to direct your questions to me.

323 thoughts on “Scope of Practice With Nurse Practitioners”

  1. Hello Dr Balasa, I noticed this question was asked earlier and your reply addressed Nebraska instead of Nevada. Can you please clarify:

    Can a NP supervise a medical assistant independently onsite in Nevada?

    1. Thank you for your question. Nevada law permits nurse practitioners to delegate to and supervise medical assistants when a physician is not on premises. I will e-mail you the relevant excerpts from the Nevada law.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  2. Hello Dr Balasa,

    I am a bit confused with this interpretation by NSBN for APRN ( see below). Per the interpretation below, does this mean as a solo-practice APRN with MA’s working with me, I have to do all the waive tests, give oral medication and injections? Please advice.

    C. NEW BUSINESS
    1. Orientation of new committee members: New member Elaine Cudnik, MSN, RN, CPNP,
    was welcomed to the committee.
    2. Legislative update: F. Olmstead informed the committee that no bills have been
    introduced that are directly related to nursing. However, bills regarding staffing ratios,
    the CARE Act and the PMP will be monitored closely by NSBN staff. D. Scott added
    that she will participate in a panel discussion during Nurses’ Day at the Legislature
    regarding APRN practice in Nevada since the implementation of AB170.
    3. Review and discussion regarding the role of APRNs working with medical assistants: D.
    Scott explained the NSBN does not have jurisdiction over medical assistants (MAs). She
    clarified that APRNs may supervise MAs but they may not delegate nursing tasks to
    MAs and the MA may not work under the APRN’s license. Further, MAs may only do an
    invasive procedure when the delegating physician or physician’s assistant is immediately
    available to exercise oversight in person while the MA performs the task. The MA is
    working under the physician’s or the physician assistant’s license who is responsible for
    and who is delegating the actions of the MA. An APRN may supervise an MA as long as
    the MA is only doing things such as vital signs, weights, or putting the patient in a room
    in anticipation of their visit. MAs may implement the orders written by an APRN that
    include the administration of medication or injections, etc., but MAs may only do those
    delegated tasks if the physician or physician’s assistant is immediately available. She
    added that further questions regarding what MAs may or may not do should be directed
    to the Board of Medical Examiners or the Board of Osteopathic Medicine.

    Click to access APRNAC-Draft-Minutes-2.24.15.pdf

    1. Let me provide excerpts from the Nevada nursing law. Note especially the underlined language.

      NAC 632.222  Delegation and supervision of nursing care. (NRS 632.120)

      1.  A registered nurse may delegate nursing care to other personnel and supervise other personnel in the provision of that care if those persons are qualified to provide that care.
      NAC 632.046  “Delegable nursing duty” defined. (NRS 632.120)  “Delegable nursing duty” means a duty which is included in the standard policies and procedures of an agency that employs a nurse and which leads to predictable results in the observation and care of patients.

      (Added to NAC by Bd. of Nursing, eff. 5-9-96)

      NAC 632.047  “Delegation” defined. (NRS 632.120)  “Delegation” means entrusting the performance of a delegable nursing duty to a person who is qualified and competent to perform the duty.

      (Added to NAC by Bd. of Nursing, eff. 5-9-96)

      NAC 632.248  Assignment to unlicensed personnel of certain nursing duties prohibited; exception. (NRS 632.120)  Except as otherwise provided in NAC 632.226, unlicensed personnel may not be assigned those duties which require the knowledge and skill of a licensed professional nurse or a licensed practical nurse as described in chapter 632 of NRS.

      (Added to NAC by Bd. of Nursing, eff. 11-2-87; A by R071-00, 10-20-2000)

      NRS 632.0169  “Practice of nursing” defined.  “Practice of nursing” means the general observation, diagnosis and treatment of changes in a person’s health. The term does not include acts of medical diagnosis or prescription of therapeutic or corrective measures, except as authorized by specific statute.
      (Added to NRS by 1989, 2050)
      NRS 632.017  “Practice of practical nursing” defined.  “Practice of practical nursing” means the performance of selected acts in the care of the ill, injured or infirm under the direction of a registered professional nurse, an advanced practice registered nurse, a licensed physician, a physician assistant licensed pursuant to chapter 630 or 633 of NRS, a licensed dentist or a licensed podiatric physician, not requiring the substantial specialized skill, judgment and knowledge required in professional nursing.
      (Added to NRS by 1987, 1525; A 1993, 2218; 1999, 1325; 2001, 1, 792; 2007, 1828; 2013, 2071)
      NRS 632.018  “Practice of professional nursing” defined.  “Practice of professional nursing” means the performance of any act in the observation, care and counsel of the ill, injured or infirm, in the maintenance of health or prevention of illness of others, in the supervision and teaching of other personnel, in the administration of medications and treatments as prescribed by an advanced practice registered nurse, a licensed physician, a physician assistant licensed pursuant to chapter 630 or 633 of NRS, a licensed dentist or a licensed podiatric physician, requiring substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical and social science, but does not include acts of medical diagnosis or prescription of therapeutic or corrective measures.
      (Added to NRS by 1987, 1525; A 1993, 2218; 1999, 1325; 2001, 2, 792; 2007, 1828; 2013, 2071)
      Here is my summary of the thrust of the above excerpts from the Nevada nursing law. Under the nursing law of NV and almost all other states, medical assistants are considered unlicensed professionals.

      1. RNs may delegate nursing duties to unlicensed professionals working under their direct supervision as long as the unlicensed professional is knowledge and competent in the delegated duty, and the duty leads to predictable results in the observation and care of patients.

      2. Unlicensed professionals may not be delegated acts that require “the knowledge and skill of a nurse.”

      3. An nursing act is an act requiring substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical and social science,

      Finally, because all nurse practitioners are RNs, I take the position that NV law permits APRNs to delegate to unlicensed professionals such as medical assistants tasks for which the medical assistant is knowledgeable and competent, which lead to predictable results, and which do not require the knowledge and skill of a nurse.

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  3. Pleas send me the Louisiana laws on a certified medical assistant work under direct supervision of a pa at a clinic. We are affliated with hospital but are in a seperate building. A physician is in our clinic also.
    Thank you so much

  4. Can a nurse practitioner delegate an order to give an IM or SC injection to a medical assistant in an out patient clinic, in the state of louisiana? Can you please email me this information. The louisiana state board of nurseing laws states that a nurse practitioner can delegate to a non medical personnel, see page 72. This is for the state of Louisiana, please email me information on this matter. Thank you.

    1. Thank you for your question. I will e-mail the pertinent Louisiana law to you.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  5. Hi can you email me the scope of practice in the state of New York. I work in Manhattan and I’m curious to know in detail the scope of practice.

  6. I have had this question posed in Mississippi. Can you please provide any information clarifying the scope of practice for a medical assistant, in Mississippi, under the direct supervision of an ARNP with no physician physically on-site? What about injections?

  7. I was curious if in the state of TEXAS an NP can delegate injections to an MA? I was under the impression that as long as the Dr is in the office it is ok. But what about when the DR is out? Either way I’ve heard several different sides and just want to make sure. Also what about when the Dr is out but he is part of a group, can the injection still be given if any Dr from the group is in an office? I have looked on the state board website but it is very vague and did not really answer my question. Thank you in advance for your time.

    1. Thank you for your question. I have an opinion from the Texas Board of Nursing that I will send you. Here are the pertinent excerpts:
      [cid:image001.png@01D383C0.618A4F10]
      It is my legal opinion that, in light of the above opinion of the Texas Board of Nursing, it is permissible for nurse practitioners to supervise medical assistants who are administering IM, subq, and ID injections—including immunizations/vaccinations—that have been delegated by the overseeing physician to the medical assistant.

      It is my opinion that the Texas Medical Practice Act and the regulations and policies of the TX Board of Medical Examiners permit a physician to assign to another physician who is on the premises/in the office suite and immediately available the supervision of medical assistants who are administering injections delegated to them by the first physician.

      I will email you the documents I have referenced in this email.

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  8. Can a nurse practitioner delegate an order to give an IM or SC injection to a medical assistant in an out patient clinic, in the state of Kentucky? Can you please email me this information.

    1. Thank you for your question. The regulations of the Kentucky Board of Nursing are worded generally. I will attach this one-page document to an email to you.

      It is my legal opinion that the Kentucky nursing law permits nurse practitioners to delegate to knowledgeable and competent unlicensed professionals such as medical assistants working under their direct/onsite supervision the administration of IM, subq, and ID injections—including immunizations/vaccinations.

      It is also my legal opinion that, if there is a likelihood of significant harm to a patient if an injectable substance is prepared improperly, the delegating nurse practitioner must verify the identity and the dosage of the injectable substance before it is administered by the medical assistant.

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

      1. Thank you. I want to be clear. The nurse practitioner writes the order for the injection to be given and then delegates the injection to be given by the medical assistant. The nurse practitioner is working under a collaboration with a physician, but the physician is not on site. Do you still believe this is allowed?

        Thank you again

        1. Thank you for the clarification. Because the physician is not on site, it is my opinion that the delegating NP must be on the premises/in the office suite and immediately available when a medical assistant is administering an injection delegated by the nurse practitioner to the medical assistant.

          Donald A. Balasa, JD, MBA
          Chief Executive Officer, Legal Counsel
          American Association of Medical Assistants
          Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
          The CMA (AAMA): Health Care’s Most Versatile Professional®

          1. We have been told that a licensed individual must be on site to carry out the injection order, such as an LPN or a RN, in the event that the nurse practitioner were out sick. Thoughts?

          2. It is my opinion that a licensed professional (such as an RN) must be on the premises and immediately available when a medical assistant is administering an injection delegated by a nurse practitioner.

            It is my opinion that the Kentucky nursing law does not require an RN or LPN to administer an injection if an NP is not on the premises. However, if a medical assistant administers the injection, there must be an RN on the premises and immediately available.

            Donald A. Balasa, JD, MBA
            Chief Executive Officer, Legal Counsel
            American Association of Medical Assistants
            Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
            The CMA (AAMA): Health Care’s Most Versatile Professional®

  9. Hi. I know someone asked about Colorado law, but could you be more specific? I work at a university medical campus with a hospital on campus in a nurse practitioner run clinic without a physician involved. If a nurse practitioner who is on site directs me to give a vaccination or other medication to a patient, can I do it? Also, am I able to give a ppd? Can a nurse practitioner sign a standing order for vaccinations? I am getting conflicting opinions on these things.

    1. Thank you for your question. Colorado law permits unlicensed professionals such as medical assistants to work under nurse practitioner supervision. I email you the information.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  10. What about in the State of Maryland a Medical assistant working under a Nurse Practitioner only in private practice.

    1. Here is the relevant Maryland nursing law. Medical assistants are considered unlicensed professionals under the MD nursing law:

      Md. HEALTH OCCUPATIONS Code Ann. § 8-102

      HEALTH OCCUPATIONS
      TITLE 8. NURSES
      SUBTITLE 1. DEFINITIONS; GENERAL PROVISIONS

      Md. HEALTH OCCUPATIONS Code Ann. § 8-102 (2014)

      § 8-102. Scope of title
      ……

      (b) Conduct not prohibited. — Except as specifically provided in this title, this title does not limit the right of:

      ……

      (3) An unlicensed individual to perform acts of registered nursing or acts of licensed practical nursing:

      (i) While supervised by an individual who is authorized by this State to practice registered nursing or licensed practical nursing; and

      (ii) If the unlicensed individual performs only acts that are in the area of responsibility of the supervisor and under the instruction of the supervisor.

      The following is also from the Maryland nursing law:
      10.27.11.03
      .03 Criteria for Delegation.
      A. The nurse may delegate the responsibility to perform a nursing task to an unlicensed individual, a certified nursing assistant, or a medication technician. The delegating nurse retains the accountability for the nursing task.
      B. A nursing task delegated by the nurse shall be:
      (1) Within the area of responsibility of the nurse delegating the act;
      (2) Such that, in the judgment of the nurse, it can be properly and safely performed by the unlicensed individual, certified nursing assistant, or medication technician without jeopardizing the client welfare; and
      (3) A task that a reasonable and prudent nurse would find is within the scope of sound nursing judgment.
      C. A nursing task delegated by the nurse may not require the unlicensed individual, certified nursing assistant, or medication technician to exercise nursing judgment or intervention except in an emergency situation.
      It is my legal opinion that the above language from the Maryland nursing law permits nurse practitioners to delegate to knowledgeable and competent medical assistants working under their direct/onsite supervision the administration of IM, subq, and ID injections.

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  11. Two months ago a nurse practitioner gave me a knee injection. I felt something was very wrong the next day. The doctor was not in the room or the building. So now I have been having sever pain in my knee for two months now. I went to the emergency room and I need a MRI. They think she ruptured my patallar tendon. My question is was he legally allowed to perform that procedure?

  12. I live in Missouri, im a MA working under a Nurse Practitioner. Can a Medical Assistant give injections and med refills under a nurse Practitioner? We have MD in office that the NPs work under. Ive been told by my office manager that i am allowed to but but my nurse practitioner says its againt state law.

    1. Thank you for your question. I have some position statements of the Missouri Board of Nursing that should shed light on what you may and may not be delegated by a nurse practitioner. I will attach these to an email to you.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  13. In Colorado— Can a medical assistant, who is working under the direction of a nurse practitioner, administer Vivitrol intramuscular injection to a patient? Vivitrol is a long actin opioid antagonist (opioid blocker).

  14. In Colorado: what are the laws regarding the role of a medical assistant in a clinic that is solely run by board-certified nurse practitioners? Whan can we NPs delegate to the MA? Can the MA call in medication refills? Can the MA administer to the patients intramuscular Vivitrol— a long acting opioid blocker? Can the MA assess and record vital signs?

    Thank you.

  15. Can I have information regarding if an NP and PA-C can delegate to a medical assistant in Pennsylvania? Specifically if a medical assistant can perform delegated tasks without a physician “on-site”? Does on-site mean they are on-site at times or does it mean that they need to be on-site at all times the medical assistant is performing any delegated duties?

    1. Thank you for your question. I will send to your email the information about the Pennsylvania law regarding physician assistants and nurse practitioners delegating or overseeing the performance of tasks by unlicensed professionals such as medical assistants.

      The Pennsylvania law regarding physician assistant delegation or supervision is standard, but the law of nurse practitioner delegation to medical assistants is more stringent than the law in most other states.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  16. Hello-

    Can you please email me the information you have and your legal opinion on APRN’s delegating medication administration to CMA’s within an outpatient clinic setting in the State of Louisiana? The APRN’s at our clinic have collaborative agreements with our physician’s but the physician’s are not always onsite.

    Are there any training requirements of the CMA that the clinic must undertake that are in addition to their certification regarding medication administration for an APRN to delegate this task to a CMA?

    Thank you!

    1. Thank you for your question. I will email the appropriate Louisiana law to you.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

    1. Thank you for your question. Go to http://www.aama-ntl.org and click below “State Scope of Practice Laws” on the left side of the homepage. You will be able to find the medical assisting law of most states, including Tennessee.

      I will email you additional information.

      I hope you find this helpful.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  17. I work in a small clinic inside of a hospital in Montana which doesn’t recognize NPs overseeing CMAs. PAs can oversee CMAs. My question is; can I refuse to work under an NP in an urgent care clinic? Management wants us (CMAS) to cover weekend shifts, but I find this a big risk to my certification.
    M.D.s are not always in the facility on weekends, but can be reached by phone.

    1. Thank you for your question. There is language in the Montana nursing law that permits RNs and APRNs (including nurse practitioners) to delegate tasks to unlicensed assistive personnel (UAP). Medical assistants would fall into this category. I will send you an email with the relevant Montana nursing law.

      Thus, the answer to your question is that it is legal under MT law for medical assistants to work under the authority of a NP. Therefore, doing so would not jeopardize your CMA (AAMA).

      I hope this is helpful. I will email you the relevant Montana law.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  18. I have seen several questions regarding admin of inj/vaccines under the supervision of a nurse practitioner in the state of Mississippi. Would you email the info to me please?

    1. Thank you for your question. Go to http://www.aama-ntl.org and click below “State Scope of Practice Laws” on the left side of the homepage. You will be able to find the Arizona law regarding physician delegation to medical assistants.

      I will attached the AZ nurse practitioner delegation provision to an email to you.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Sets the Bar for Excellence in Medical Assisting

  19. I am working in a rather new field. I work for a company that provides home health, hospice, and provider services. I run the provider service department. Meaning I have 5 NP-C that go out to pts house or to facility to see pt rather then the pt coming to us. My problem is that corporate has blocked me from creating orders for labs and scans and for sending refills on prescriptions. These are things every clinic I have ever worked for allows. I am hoping you have some documentation for the state of Idaho that would help me clarify the scope of practice for this in Idaho so I can better run my department. My providers all want this to be addressed as they agree that I should be allowed to complete these duties. As of now I have to call them to sign every order and refill. To them they feel they may as well not have an assistant. Please help us plead our case

    1. Thank you for your question. I will respond to your email address.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Sets the Bar for Excellence in Medical Assisting

  20. Can you share your opinion if an MA can give an injection or vaccinations in the state of Kansas under the sole supervision of a FNP? Thank you.

    1. Thank you for your question. It is my legal opinion that the Kansas nursing law permits family nurse practitioners to delegate to knowledgeable and competent unlicensed professionals such as medical assistants working under their direct/onsite supervision the administration of certain types of injections, including vaccinations/immunizations. I will send the document of my opinion to your email address.

      Donald A. Balasa, JD, MBA
      CEO and Legal Counsel, AAMA
      dbalasa@aama-ntl.org

  21. What does my scope of practice cover under a NP in the state of MS? Specifically calling in prescriptions. The clinic I work at wants to train me to do x-rays as well. Anything I can do to help out the nurses in my clinic will be helpful. Thanks in advance.

  22. Can a Physicians Assistant being managed by an MD delegate the administration of injections (immunizations, depo-medrol, rocephin) by a CMA if MD is on-site in the state of South Carolina?

  23. South Carolina law permits nurse practitioners to delegate certain tasks to unlicensed allied health professionals such as medical assistants. Could you please let me know what certain tasks these are? Also, under SC Law, can a MA place a Unna boot on a Patient?

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s