Advanced Practice Registered Nurses (APRNs) in Florida are highly trained health care professionals, equipped with specialized education and training, and are often on the front lines of providing essential health services to diverse patient populations.
With the introduction of the 2021 Florida law on the Autonomous APRN practice, Florida licensed APRNs are now free to register to operate independently, without physician supervision, to deliver primary care health services. In the first quarter of 2023, there were approximately 8,185 APRNs registered for autonomous practice, and I suspect this number will continue to grow in the coming years. In this post, I cover the main requirements to become an autonomous APRN (excluding certified nurse midwifes), along with some discussion on select nuances of this law.
Eligibility Requirements for Autonomous APRN Practice in Florida
To be eligible to register as an autonomous advanced practice registered nurse in Florida, you must satisfy these 4 requirements:
You hold an active, unencumbered APRN license.
You have not been the subject of any disciplinary actions specified in sections 456.072 or 464.018 of the Florida Statutes within the 5 years immediately preceding your application for registration.
You’ve completed at least 3,000 clinical practice hours within the 5 years immediately preceding your application for registration while practicing as an APRN under the supervision of a licensed physician. This can include clinical instructional hours provided by you. Section 464.0123(1)(c) defines “clinical instruction” to mean "education provided by faculty in a clinical setting in a graduate program leading to a master’s or doctoral degree in a clinical nursing specialty area.”
Within the past 5 years, you’ve completed 3 graduate-level semester hours (or 45 CE credits as its equivalent) in Differential Diagnosis and 3 graduate-level semester hours (or 45 CE credits as its equivalent) in Pharmacology.
Liability Coverage Required
In addition to the above registration requirements, to be eligible to engage in an autonomous practice as an APRN, you must have an acceptable form and amount of liability coverage to pay for any claims and related costs that may arise out of your providing, or failing to provide, nursing care, treatment, or services. This can be either of the following:
Professional liability coverage of at least $100,000 per claim with a minimum annual aggregate of at least $300,000; or
An unexpired, irrevocable letter of credit in an amount of at least $100,000 per claim with a minimum aggregate availability of credit of at least $300,000 and which is payable to you, the APRN, as the beneficiary.
This liability coverage requirement does not apply in the following 4 scenarios:
You practice exclusively as an officer, employee, or agent of the Federal Government or of the state or any of its agencies or its subdivisions.
Your registration as autonomous APRN is inactive, and you are not practicing as an autonomous APRN.
You practice only in conjunction with your teaching duties at an accredited school or its main teaching hospital and that practice is limited to that which is incidental and necessary to perform your teaching duties.
You're registered an as autonomous APRN, but you are not actually engaged in an autonomous practice. As a side note, if you fall in this category and you plan to start or resume an autonomous practice, you must notify the department and have the requisite liability coverage.
APRN Autonomous Practice is Limited to Primary Care
The scope of an APRN autonomous practice in Florida is limited to a primary care practice, which includes family medicine, general pediatrics, and general internal medicine.
Primary care practice is defined to mean and include “'physical and mental health promotion, assessment, evaluation, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses, inclusive of behavioral and mental health conditions.'” See Fla. Admin. Code Ann. R. 64B9-4.001(12).
In other words, you're allowed to practice autonomously without a doctor’s supervision but only in the field of primary care services, which includes family medicine, general pediatrics, and general internal medicine. This covers a wide range of healthcare services, including promoting physical and mental health, assessing and evaluating the health of patients, preventing diseases, and maintaining overall health. This also includes counseling patients, educating them about their health, and diagnosing and treating acute and chronic illnesses. Additionally, this care involves both physical conditions and mental or behavioral health issues arising in a primary care setting.
As a registered autonomous APRN engaged in autonomous practice, you are authorized to perform the general functions of a licensed APRN as permitted under section 464.012(3) of the Florida Statutes but only as it relates to primary care. This includes, but is not limited to:
Prescribing, dispensing, administering, or ordering any drug. Note that the term “dispensing” means selling medications to patients in the office. Writing prescriptions and providing complimentary samples do not require a dispensing license because there is no sale. If you wish to sell medications in your autonomous practice, you must obtain a dispensing license. In addition, for controlled substances you can only prescribe or dispense these types of medications if (1) you have master’s degree or doctorate in a nursing clinical specialty area with preparation in specialized practitioner skills (i.e. focused, specialized training to prescribe and dispense controlled substances) and (2) you have a valid federal controlled substance registry number issued by the U.S. Drug Enforcement Administration (DEA). Additionally, unless you are also a psychiatric nurse, you are required to limit your prescription of any Schedule II controlled substance listed in Section 893.03 of the Florida Statutes to a 7-day supply.
Ordering diagnostic tests and physical and occupational therapy.
Ordering medication to administer to a patient in a licensed facility, such as a hospital, an ambulatory surgical center, a long-term care facility, and a nursing home, among others.
Ordering physical and occupational therapy.
Initiating, monitoring, or altering therapies for certain uncomplicated acute illnesses.
Monitoring and managing patients with stable chronic diseases.
Establishing behavioral problems and diagnosis and recommending treatment.
Performing a subcutaneous procedure. No other type of surgical procedure is allowed, including performing any dermatologic or skin care services including aesthetic skin care services. This exclusion applies to Med Spas providing aesthetics, injectables or IV hydration. This is because a Med Spa is not considered a primary care practice. Under sections 458.348 and 459.025 of the Florida Statutes, which govern supervisory relationships, “practices providing primarily dermatologic and skin care services, which include aesthetic skin cares” are expressly excluded from the scope of primary care. In addition, the Florida Board of Nursing has expressly opined that the scope of practice for registered nurses excludes aesthetic injections (such as dermal fillers and Botox) even where a registered nurse has specialized education and training to perform such services. Accordingly, if you desire to open a Med Spa to provide such services, you are still required to have a collaborative agreement and protocol with a qualified supervising physician, such as dermatologist or plastic surgeon.
For patients requiring the services of a health care facility (i.e., a skilled nursing facility, hospice, or intermediate care facility for the developmentally disabled), you can admit the patient to the facility, manage the care received by the patient in the facility, and discharge the patient from the facility unless the discharge is prohibited by federal law or rule. Note that a facility that solely relies on spiritual means through prayer for healing is excluded.
Signing, certifying, stamping, verifying, providing an affidavit, or endorsement that is otherwise required by law to be provided by a physician except for the medical use of marijuana.
Signing a Florida Certificate of Death.
Admitting a patient for psychiatric evaluation pursuant to the Baker’s Act.
Certifying, establishing, and periodically reviewing the plan of care, as well as supervising the provision of items and services for beneficiaries under the Medicare home health benefit.
A registered autonomous APRN engaged in autonomous practice must renew the registration every 2 years. This renewal coincides with the renewal period for your APRN license. To renew, you must have completed at least 10 hours of approved continuing education in addition to completing the 30 hours of continuing education that is required for renewing your APRN license.
Required Patient Disclosures for APRN Autonomous Practices
As a registered autonomous APRN engaged in autonomous practice, you are required to inform your new patients, in writing, about your qualifications and the nature of your autonomous practice before or during your initial patient encounter.
There are a number of ways you can make this disclosure to satisfy this requirement. For example:
Including the disclosure in your New Patient Welcome Packet, informing your new patients about your qualifications and specifics of your practice. This packet may be provided to your new patients during their initial visit or sent to them digitally in advance of their first appointment.
Sending new patients an email or text (if you have their advanced consent to do so) prior to their initial appointment, providing them with details about your credentials and the nature of your practice.
Placing visible posters or digital screens in your practice’s waiting room that presents sufficient information about your qualifications and practice that they can read while they wait.
Including the disclosure in brochures that can be handed out during the initial visit or made available in the waiting room.
If your practice has a website, post the disclosure in a standalone webpage or include a section within a webpage that details your qualifications and outlines the nature of your practice.
If your practice uses a patient portal, providing the disclosure in a communication within their personal dashboard that informs them of your credentials, experience, and the scope of your practice. Separately, but equally important, do ensure that whatever patient portal you select for your practice is secure and complies with HIPAA requirements.
This list of examples do not represent an exhaustive list of all the ways you can make this disclosure, but should provide you with some ideas to get you going. Whether you use one or a combination of approaches to make this disclosure, the goal is to ensure your new patients are properly informed, comfortable with your qualifications and nature of your practice, and satisfy your disclosure obligations.
Standards of APRN Autonomous Practice
An advanced practice registered nurse engaged in autonomous practice must practice in accordance with the General Standard of Practice. The General Standard of Practice means "that standard of practice, care, skill, and treatment which, in light of relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similarly situated, educated and licensed [APRNs].” See Fla. Admin. Code Ann. R. 64B9-4.021.
What is considered "acceptable and appropriate" is determined by what similar, well-educated, and licensed APRNs would deem suitable in the same circumstances. Basically, you’re expected to practice with the same level of care and skill that any other reasonably competent APRN would do under similar conditions. If in doubt, don’t act but do ask, and only proceed after you've obtained appropriate guidance.
Starting a primary care practice as an autonomous APRN opens new opportunities for professional growth, professional independence, and a means to help shape the delivery of healthcare services in Florida. This fairly new opportunity is certainly exciting for APRNs with an entrepreneurial mindset, but it's important to recognize that such independence comes with greater responsibility. In addition to your professional responsibility to deliver quality care, you will also have new responsibilities involving business operations, financial management, and legal and regulatory compliance, just like any other health care professional who owns a medical practice. As such, ensure you are well-informed, remain updated, plan strategically, and take actionable steps accordingly.
Lastly, and as always recommended, do seek the appropriate professional advice to help ensure that your new venture is set up and operated for optimal business growth and in compliance with applicable Florida state and federal laws, rules, and regulations.
The information provided in this post is for general informational purposes and not intended as legal advice or legal opinion for any individual matter. Keep in mind that legal developments or changes to law may occur in the future and, as such, the information contained in this post may not be the most up-to-date legal or other information. Do consult your own attorney for any legal advice you may require. If you do not have an attorney and would like to explore a potential engagement for my services, please reach out to me via the contact submission form or by using the contact information provided in my bio.