Carolyn Buppert, a healthcare lawyer, answers a question from an advanced practice registered nurse on whether she should be expected to function as an APRN and regular registered nurse (RN). APRNs are taking on more functions previously associated with primary-care physicians, both to  increase the number of clinicians who can serve the burgeoning number of patients and to save money since nurses are paid less than physicians.

Ms. Buppert’s answers, in part:

“Legally, you can do both. So that means that this is an issue of patient safety and also an issue of personnel management. I can envision two ends of a spectrum. On one end, the APRN is being spread too thin, time-wise, and advanced practice is suffering because of the RN-practice duties that need attention. That could be a risk management problem, because the APRN could overlook patient follow-up or fail to ask a pertinent question of a patient, resulting in a missed diagnosis and a lawsuit against the APRN and employer. One the other end, if the clinic has just a few patients on any given day, it makes sense, personnel-wise, to have an APRN run the clinic alone. This arrangement could be safe.

“One way to present the issue to management is to track how many days each week you are scheduled to see more than a threshold number of patients. For discussion purposes, let’s set the threshold at 15 established patients in adult internal medicine in an 8-hour day. The number could be higher – 20 patients per day — for pediatrics, some family practices, and some practices where the level of visit is current procedural terminology (CPT) codes 99212 to 99213. The number could be lower for new patients and if the patients require evaluation and management at the higher CPT levels.

“If the schedule is for more patients than the threshold number, then you should have a fairly strong argument that you need an assistant. Whether that assistant is RN level or a medical assistant depends on the level of service needed. You might check with colleagues at other clinics to determine their threshold for having one or more assistants.”

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