The practice of medicine and nursing is defined and regulated by state law. Most of the federal regulations on medical practice and payment for medical care defer to the state’s rules on what is allowable practice. If one state allows nurses to do what another state restricts to physicians, a very common situation, the federal government will pay the nurse in the permissive state and not in the restrictive state. Since these rules vary greatly from state to state, physicians, nurses, and other NPPs should obtain their state’s licensing laws and regulations and familiarize themselves with them.

All states reserve some aspects of medical care to licensed physicians, such as performing surgery. All states allow NPPs to do some activities without any physician supervision, such as changing wound dressings and taking blood pressures. Between these two extremes, the NPPs practice on the delegated authority of a licensed physician. For these activities, the physician is charged with supervising the NPP, either directly or through protocols and physician’s orders. Depending on the activity and the state, the physician must be in the same room, in the same building, or may supervise at a distance, so long as he or she is available by telephone in emergencies. Physicians and NPPs who do not comply with their state’s regulations on supervision and independent practice can lose their licenses, [ Sermchief v. Gonzales, 660 S.W.2d 683 (Mo. 1983).] be criminally prosecuted for unauthorized practice of medicine, or be prosecuted for Medicare/Medicaid fraud if they bill the government for improperly delegated tasks. [People v. Varas, 110 A.D.2d 646, 487 N.Y.S.2d 577 (N.Y.A.D. 2 Dept. 1985).]

There are three issues to consider when delegating authority: (1) the legality of the delegation, (2) the proper method of delegation, and (3) the physician’s oversight responsibilities for the delegated duties. These issues must be considered within the context of the three classes of medical tasks. The first class is tasks that are freely assignable; they are not unique to medical care delivery and do not require the exercise of professional judgment. They include billing and patient accounts, maintaining simple medical equipment, and other nonpatient care activities that accompany the practice of medicine. The supervising physician must ensure that the activities meet the necessary legal standards for protecting patient confidentiality and any other statutory requirements, but they do not need to be done by licensed medical professionals.

The tasks in the second class are those that may be assigned to a limited class of persons. These tasks, such as nursing activities and laboratory analyses, require professional skills and judgment. They also may include activities that require physician supervision, such as recommending treatments to patients. Activities in the third class of medical tasks are reserved solely to physicians; delegation may violate criminal laws against aiding in the unauthorized practice of medicine. These activities include performing surgery, directly supervising nonphysician personnel in physician- only activities, and writing prescriptions for controlled substances. State law and tradition determine which specific activities cannot be delegated.