OHIP Billing

When ordering tests, NPs must include their OHIP billing number on the requisition. This number authorizes the laboratory or diagnostic facility to bill the Ontario Health Insurance Plan (OHIP) for the tests. For more information on how to obtain an OHIP billing number, contact the Ministry at 1 800 268-1154 (416 314-5518 in Toronto) or visit OHIP’s website to download the Application for OHIP Billing Number for Health Professionals (No. 3384-83).

Laboratory Tests

Many quality issues that result in a laboratory's rejection of a specimen can be resolved through upfront communication between the provider ordering the test and the local laboratory.

NPs who have questions about laboratory policies and procedures for ordering tests and collecting, labeling, storing and transporting samples are encouraged to consult the laboratory prior to ordering the test to mitigate the risk of specimen rejection. For further information, refer to the Ontario Association of Medical Laboratories' Guidelines.

NPs are authorized to apply ultrasound. Ultrasound means any ultrasound that uses soundwaves to produce an image or other data.

When applying ultrasound, NPs are accountable to the expectations set out in CNO’s practice standards including Nurse Practitioner and Scope of Practice.

Palliative Care Facilitated Access Program for NP Prescribers

On February 9, 2018, the Palliative Care Facilitated Access (PCFA) Drug Products mechanism was expanded to include certain NPs./p>

The Ministry of Health and Long Term Care identified both the Nurse Practitioners’ Association of Ontario (NPAO) and the Registered Nurses’ Association of Ontario (RNAO) as organizations that can determine if an NP meets the eligibility criteria to be registered as a PCFA NP Prescriber.

The PCFA registration will enable NPs who are authorized to prescribe controlled substances and have demonstrated expertise in palliative care to prescribe high-strength opioids for palliative purposes.

The criteria to be registered as a PCFA NP Prescriber was recently revised by the Ministry. AN NP who wishes to be added to the PCFA Prescriber list must:

• hold current certification in the extended class with the College of Nurses of Ontario
• be authorized to prescribe controlled substances
• have no restrictions on the NP certification that impact their ability to practise, and
• provide evidence of continuing education in palliative and end-of-life care.
  

In addition, the NP must meet at least one of the following requirements:

• Provide 20 or more palliative care consults or assessments within a year
• Provide 30-50 or more palliative care visits within a year
• Be identified by the NP’s employer as an a provider of palliative care
• Work in collaboration with a palliative care physician or PCFA-approved NP

All NPs in Ontario are able to register as PCFA prescribers if they meet the eligibility requirements. To remain on the prescriber list, NPs are required to reapply annually to ensure they continually meet eligibility criteria.

If you wish to apply to the PCFA NP prescriber list or to obtain further information, send an email to either of the following organizations:

Nurse Practitioners’ Association of Ontario (NPAO) – admin@NPAO.org
Registered Nurses’ Association of Ontario (RNAO) – PCFA@RNAO.ca

Ontario Drug Benefit (ODB) Program

The Ontario Drug Benefit Program (ODB) provides drug benefits for eligible Ontarians. The ODB eligibility includes all OHIP-insured children and youth aged 24 and under.

Prescriptions written by NPs and dispensed in Ontario are ODB-eligible. NPs must include their College registration number on prescriptions.

NPs who prescribe medications to ODB-eligible clients must have an OHIP billing number. This number is not required on the prescription unless you are prescribing a monitored drug. This number is used by the Ministry when adjudicating claims. For more information, or to obtain a billing number, contact the Ministry at 1 800 268-1154 (416 314-5518 in Toronto) or visit OHIP's website to download the Application for OHIP Billing Number for Health Professionals.

The ODB formulary is regularly updated and published. Information about ODB and other Ontario public drug programs is available from the Ministry of Health and Long-Term Care.

Therapeutic products listed on the Formulary, such as diabetes testing strips and nutritional products prescribed by NPs, are ODB-eligible.

Limited Use Drugs

The criteria for limited use drugs may or may not identify specific prescribers. For example, some limited use drug criteria specify that only physicians can prescribe them. NPs may also be specified in the criteria. Where the criteria includes NPs or does not identify specific prescribers, NPs are able to prescribe a limited use drug and the drug would be eligible for coverage under the ODB Program. In this case, NPs may prescribe a limited use drug if the client satisfies ODB-listed limited use criteria. NPs need to write the limited use code on the prescription, and limited use prescriptions must include a limited use or nutrition product form that indicates the reason for use. To determine if a medication is covered under limited use, visit the Ministry’s Formulary Search.

Exceptional Access Program (EAP)

ODB can accept an NP prescription under the EAP. More information about the EAP is available on the Ministry's website.

Special authorization digital information exchange

The Special Authorization Digital Information Exchange (SADIE) is the portal for submitting Exceptional Access Program (EAP) drug requests for Ontario Drug Benefit (ODB) recipients. SADIE is available to Ontario Nurse Practitioners, Physicians and their assigned delegates or designates.

The EAP provides access to drugs that are not on the ODB list of prescription drugs in order to ensure patient safety, manage costs, ensure compliance with progression of therapies, etc. EAP requests are reviewed individually against clinical criteria. To receive coverage for the requested drug, the patient must be receiving benefits under the ODB program.

To learn more, visit SADIE at www.Ontario.ca/SADIE.  

Lost or Stolen Prescriptions

To prevent prescription fraud, NPs are expected to adopt strategies such as reducing the risk of lost or stolen blank prescriptions. In the event of lost or stolen prescriptions, work with the employer to manage risk and determine whether a report to police is appropriate and in keeping with Ontario’s health privacy law. Inform Ontario Public Drug Programs of lost or stolen prescriptions by sending an email to publicdrugprgrms.moh@ontario.ca or calling 1-866-811-9893 – they will notify pharmacies about missing prescriptions to reduce the potential for fraud.

Health Canada’s Special Access Program (SAP) allows practitioners to request access to drugs that are unavailable for sale in Canada. This access is limited to clients with serious or life-threatening conditions on an emergency basis when conventional therapies have failed, are unsuitable, or are unavailable. NPs may request special access to medications that they are legally authorized to prescribe. NPs should consider the additional risks associated with prescribing SAP medications, and discuss these risks with the client. NPs may also wish to consult their professional liability protection provider to address any liability concerns. More information about the SAP, and requirements that practitioners must meet, is available on Health Canada’s website. For information about NPs’ professional accountabilities related to therapeutic management, see the Nurse Practitioner practice standard.

Assistive Devices Program (ADP)

The ADP helps eligible Ontarians with long-term physical disabilities access and pay for personalized assistive devices. The Ministry accepts NP authorization forms for several devices and supplies. For more information on the type of devices and the circumstances in which NPs can complete authorization forms, call the Ministry at 1 800 268-6021 (416-327-8804 in Toronto) or visit the Ministry website.

Ontario Disability Support Program (ODSP)

ODSP provides income and employment support to eligible Ontarians. When assessing an individual’s eligibility for income support, ODSP accepts an NP’s assessment of a client’s physical or mental impairment and the expected duration of that impairment. As well, NPs can complete an application for a special diet allowance for eligible recipients. For more information about ODSP, visit the Ministry's website.

Workplace Safety and Insurance Board (WSIB)

The Workplace Safety and Insurance Board (WSIB) recognizes NPs as service providers. To bill WSIB, NPs must obtain a WSIB provider identification number. To register for electronic billing please complete the Provider Registration online form.  For more information, call 416 344-4526 or 1 800 569-7919.

Ontario Disability Tax Credit

Federal legislation authorizes NPs in Canada to sign Form T2201, the Disability Tax Credit Certificate. NPs completing this form are accountable to the standards including the Documentation and Nurse Practitioner practice standards.

Hospital Privileges

NPs who are employees of a hospital are authorized to order diagnostics and treatments for hospital patients (in-patients and out-patients). NPs who are not hospital employees may apply to the hospital for these privileges; however it is up to the discretion of the hospital whether they will grant privileges.

Regulation 965 under the Public Hospitals Act specifies that the hospital’s Medical Advisory Committee (MAC) can make recommendations to the hospital board about granting privileges to NPs who are not hospital employees. The hospital’s MAC is also responsible for the overall supervision and quality of the practice of NPs who have been granted hospital privileges. To apply for hospital privileges, contact the individual hospital.

Admitting and Discharging Clients

NPs are authorized to admit and discharge hospital patients. The process for an NP to admit and discharge clients is up to the discretion of the hospital. An NP should always consult with the facility for further information on its policies.

Under the Health Protection and Promotion Act, NPs have a duty to report certain diseases to the medical officer of health in their local public health unit, if they suspect or know that a person has or may be infected with a communicable disease.

The Ministry of Health has a list of the local public health units in Ontario and their locations.

For a list of reportable diseases and infectious agents, as well as instructions on reporting, contact your local public health unit.

Reporting to the local public health unit

In facilities (such as, hospitals and long-term-care homes), it is the employer's responsibility to report diseases or infectious agents. If you work in a facility, consult the applicable facility policies and procedures on how reporting will take place.

In addition, NPs have a duty to report when a client refuses or neglects treatment for a communicable disease. A report containing the client’s name and address should be made to the medical officer of health in their local public health units.

If an NP certifies death where a communicable disease was a cause or contributing factor of the client’s death, this information must be reported to the local public health unit. For information about the circumstances in which NPs are authorized to certify death, see Issuing Medical Certificates of Death (below).

An NP who has information about any animal bite or other animal to human contact that may result in rabies must report the information to the local medical officer of health as soon as possible.

Electronic Medical Certificate of Death

The Ministry of Government and Consumer Services has expanded the use of the electronic Medical Certificate of Death (eMCOD) to include physicians and NPs providing palliative care outside of a hospital setting (e.g., patient’s place of residence, hospice, long-term care home). 

This is not mandatory but NPs and physicians have the option to use the eMCOD to electronically and securely complete, certify and submit the form directly to the funeral home.

If you have issues accessing the eMCOD form or for instructions or questions about using the form, contact MCOD.support@ontario.ca.

Immunization of School Pupils

Under the Immunization of School Pupils Act, NPs are authorized to complete a statement that exempts a child from a childhood immunization required for school attendance in Ontario. The conditions under which an exemption may be provided are:

the immunization may be detrimental to the health of the client (i.e., the child is known to be allergic to a substance in the vaccine), or
the immunization is unnecessary because the client is already immune (i.e., there is laboratory evidence of immunity).

Immunization reactions

Under the Health Protection and Promotion Act, NPs have a duty to report to the medical officer of health in their local public health unit, any of the following immunization reactions:

a) Persistent crying or screaming, anaphylaxis or anaphylactic shock within 48 hours after immunization

b) Shock-like collapse, high fever or convulsions within 3 days after immunization

c) Arthritis within 42 days of immunization

d) Generalized urticaria, residual seizure disorder, encephalopathy or any other significant occurrence within 15 days of immunization

e) Death occurring at any time or death following any of the above.

NPs must make the report within 7 days of determining that a client has, or may have, experienced any of the above reactions.

In addition, when health care workers are obtaining consent for immunizations, they must provide education to clients about the importance of immediately reporting to a physician or NP, any reaction that might be a reportable event.

Parking Permits

NPs can complete the Application for Accessible Parking Permit form (SRLV-129 07-08) for clients. The form is available on the Ministry of Transportation website and at any Service Ontario driver and vehicle licence issuing office.

Commercial Licence Medical Report

NPs can complete the Commercial Licence Medical Report form (i.e., drivers’ physical). For further information, visit the Medical Review Section (Commercial Drivers) of the Ministry of Transportation website.

Fitness to Drive Medical Reports

It is mandatory for NPs to report certain high risk medical conditions, functional impairments and visual impairments in clients 16 years of age or older. Details of the prescribed conditions NPs must report can be found in Ontario Regulation 340/94, s. 14.1 (3).

Also included is discretionary reporting of any person who, in the opinion of the NP, has or appears to have any medical condition that may impair safe driving.

A medical reporting form for both mandatory and discretionary reports is available through the Ontario Ministry of Transportation.

NPs are not required to report an individual if no nurse-client relationship exists.

1. Is there a requirement for me to practise as an NP in a clinical role to maintain my Certificate of Registration as an NP?

Yes. Under the Registration Regulation, NPs must maintain clinical NP practice to remain registered in the Extended Class. This clinical practice must include:

• direct interaction with the client population(s) consistent with each specialty certificate that the NP holds and
• the use of advanced nursing knowledge and decision-making skill in health assessment, diagnosis and therapeutics in the treatment of those clients.

Each year, NPs will be asked to declare if they have practised as described above within the previous three years. NPs who do not meet this requirement will not be eligible to remain registered in the Extended Class.

2. What is the declaration of practice? When do I make this declaration?

While completing the Annual Membership Renewal form each year, and at any other time upon request by the College, NPs will be required to declare whether they practised as NPs, as described in the first question above, within the previous three years. NPs who hold multiple specialty certificates in the Extended Class will be required to make this declaration for each specialty certificate they hold. Upon request by CNO, members must provide evidence to support their declaration.

3. a) I am an NP-Primary Health Care (PHC) working in a Long-Term Care home. Am I required to practice with clients in all age groups to maintain my current certificate of registration?

No. Each NP specialty certificate represents a broad client population and a wide age range. The client population for the PHC specialty is “family all ages.” Therefore, you can meet the NP declaration of practice requirement by practising, as described in the first question above, with clients in any or all age groups within your specialty. As always, you are expected to meet the practice expectations for public protection described in the Nurse Practitioner practice standard.

b) I know I must fulfil the College's QA (Quality Assurance) obligations to maintain my certificate of registration. How will my practice within the NP-PHC specialty be assessed when I'm selected for practice assessment in the QA program?

To protect the public, the QA program requires each NP to demonstrate competence for the specialty certificate in which she or he is registered. This is because NPs may work in a wide variety of practice settings and a wide range of clients are covered by each specialty certificate. In addition, Ontario law requires Colleges to assess entry-to-practice competencies through their quality assurance processes.

When you are selected to participate in CNO's QA practice assessment, you will be required to demonstrate the core competencies and the use of advanced knowledge and decision-making skill in health assessment, diagnosis and therapeutics with a primary health care "family all ages" population.

4. The clinical practice requirement doesn’t recognize that NPs contribute to the health system in many ways beyond the provision of direct client care. Why is the College requiring NPs to engage in direct clinical practice with clients?

CNO recognizes there are numerous ways in which nurses provide positive contributions to client care and the health system, and that nursing practice does not always involve direct interaction with clients. Examples include policy development, administration, research and education. CNO appropriately and safely regulates these aspects of nursing practice through the General Class.

The Extended Class exists to authorize RNs who have met specific requirements to perform certain controlled acts (e.g., communicating diagnoses, prescribing medication) that are directly linked to clinical practice. To protect the public, NPs are expected to demonstrate and maintain competence to practise in a clinical NP role. This has been an expectation under the Nurse Practitioner practice standard since October 2011. Adding this requirement to the Registration Regulation reinforces the expectations and standards, and is consistent with those of other nursing jurisdictions across Canada.

5. What happens if I have not practised in a clinical NP role in the previous three years?

If you have not practised as an NP as described in the first question in the previous three years, but have practised nursing during that time, then your Extended Class certificate will be revoked and replaced with a General Class certificate. If you have not practised nursing at all in the previous three years, then you must either register in the Non-Practising Class or resign from CNO.

6. Do NPs have to practise for a minimum number of hours to meet the NP practice requirement?

The College does not specify the number of hours that NPs must practise within the three-year timeframe. The amount of practice needed to maintain NP competence in the areas of health assessment, diagnosis and therapeutics in the treatment of clients will vary for individual NPs based on their experience, knowledge and skill level. It is up to each NP to determine how much practice is required to maintain that level of competence. NPs are also required to meet continuing competence requirements related to application of practice standards and related NP competencies.

7. Does CNO provide a list of nursing positions that satisfy the NP practice requirement?

No. Nurse Practitioners work in roles that involve various dimensions of nursing practice, including clinical and nonclinical components. Therefore, what must be determined is whether an individual NP meets the requirement as outlined in the first question, irrespective of her or his position. NPs are expected to reflect on their nursing practice and determine whether it satisfies the practice requirement.

8. I am an NP and a faculty member in an approved NP university education program. Does my position meet the evidence of practice requirement?

The College does not determine whether a position fits the requirement; it is whether an individual NP meets the requirement. You are expected to reflect on your role as a faculty member and determine whether you satisfy the practice requirement for NPs as described in the first question.

9. Does volunteering in an NP role meet the NP practice requirement?

Providing nursing services in a volunteer capacity meets the requirement if it is consistent with the definition of NP practice as described in the first question. Keep in mind that you will have to provide evidence to support your declaration if CNO requests it.

10. I am registered as an NP and hold both Adult and Paediatrics specialty certificates. I work in a role that involves providing NP health care services to an adult population. Do I meet the evidence of NP practice requirement?

You must demonstrate practice, as described in the first question, with a client population that is relevant to each specialty in which you are registered. In this case, your Paediatrics specialty certificate will be revoked if you do not practise with paediatric clients in accordance with the practice requirement for NPs as described in the first question. Assuming your practice with adult clients is consistent with the NP practice requirement, your NP registration with the Adult specialty certificate will not be affected.

If I receive a General Class certificate because I did not meet the practice requirement for NPs, what will I need to do if I want to resume practise as an NP in Ontario?

You will need to apply to reinstate your NP certificate and the specialty certificate that you previously held. To reinstate, you will have to demonstrate evidence of NP practice within the previous three years. That practice must be clinical and include:

• direct interaction with the client population(s) consistent with each specialty certificate you previously held and wish to have reinstated and
• the use of advanced nursing knowledge and decision-making skill in health assessment, diagnosis and therapeutics in the treatment of those clients.

If you have been practising as an NP in another jurisdiction, then your practice there will be assessed to determine whether it meets the above description. You may also be expected to meet other reinstatement requirements, such as successful completion of the jurisprudence exam.

Do graduates of approved NP programs have to meet the practice requirements to become registered as NPs?

Yes. Evidence of practice in the NP role is a non-exemptible registration requirement. If you completed an approved NP program within the past three years, then you will satisfy the evidence of NP practice requirement.

If it has been more than three years since you completed an approved NP program, then you must demonstrate that you have practised within the past three years in a clinical NP role that included:

• direct interaction with client population(s) consistent with each specialty certificate for which you are seeking registration and
• the use of advanced nursing knowledge and decision-making skill in health assessment, diagnosis and therapeutics in the treatment of those clients.

If you have not practised accordingly, then you will be required to undergo an evaluation approved by CNO's Registration Committee to determine whether you meet the practice requirement. The evaluation may conclude that you meet the NP practice requirement for registration, or it may identify the need for you to complete further training, experience, examinations or assessments to meet the requirement.

I am an RN who is practising in Ontario and applying to register as an NP. Why do I have to successfully complete the jurisprudence exam if I am already practising nursing in Ontario?

The jurisprudence exam is a non-exemptible registration requirement for applicants. The exam assesses an applicant’s awareness and understanding of the legislative and regulatory framework (i.e., laws, regulations, by-laws, practice standards and guidelines) that governs the nursing profession specifically in Ontario.

For NP applicants, the jurisprudence exam includes questions applicable to all nurses in Ontario and questions that are unique to NP practice. While many NP applicants are already practising nursing in Ontario as RNs in the General Class and would likely be familiar with the concepts assessed on the jurisprudence exam, they must demonstrate that they have this knowledge by successfully completing the RN(EC) Jurisprudence Examination before they can register in the Extended Class.

I am a recent graduate from a nurse practitioner (NP) program and will be writing my registration examination soon. My placement organization has offered to hire me temporarily as an NP, until I successfully pass the exam. Does CNO have a temporary class registration for new NP program graduates?

No, CNO does not have a temporary class registration for NP program graduates. Until an individual is registered as an NP with CNO, they cannot use the title, portray themselves or be employed as an NP. During this time, the nurse is a registered nurse (RN) and would function as such until they receive their registration with CNO as an NP.

It is up to the employer’s discretion to determine their hiring requirements, including whether they would like to hire an RN who has recently graduated from an NP program. Nurses are encouraged to clarify hiring policies with the potential employer and ensure they are fully aware that they cannot practice as an NP or hold themselves out as an NP until they receive registration with CNO.

See Legislation and Regulation: An Introduction to the Nursing Act, 1991 for more information on Registration categories and classes.

I just received my NP Certificate of Registration. How do I sign my name?

You must sign as either Nurse Practitioner (NP) or Registered Nurse, Extended Class [RN(EC)]. You may also add your specialty certificate designation:

1. NP-Adult
2. NP-Paediatrics
3. NP-Primary Health Care (NP-PHC)

No other variations of the NP title may be used.

I work in a clinic where the primary health care providers charge clients fees for services, such as completing forms or providing sick notes. Can I charge clients fees for these types of services?

Most NPs are salaried employees. To reduce the risk of conflict of interest, ensure there are clear parameters about whether these services are offered during regular work hours and how the revenue generated from these fees will be managed. You should work with your employer to develop a clear workplace policy about charging clients fees. Policies should be consistent with the standards and regulations governing affected health professionals. Decisions should be made in the best interest of clients and the policy should address ethical considerations, including the process for clients who cannot afford to pay a fee.

Refer to CNO’s Professional Misconduct document for information about nurses’ professional accountabilities when charging fees.

I am an NP employed at a primary health care clinic. I gave my employer notice and they will not recruit a new NP before I leave. What are my professional accountabilities in this situation? After I’ve left, can I follow-up on diagnostic tests that I have ordered?

When you are no longer employed at this clinic, you cannot access client health records, including diagnostic test results. You can only remain involved in the care of these clients if your employment is extended, or you are retained by the employer in some other way (e.g., contract), to provide health services to these clients.

You are accountable for working with the employer to facilitate continuity and transfer accountability of client care. This may include strategies such as: notifying clients and giving them information about how their health care needs will be met, prioritizing high-risk clients for appointments, and ensuring the employer is aware of pending diagnostic test or lab results.

The employer is responsible for ensuring strategies are in place to meet client-care needs while they recruit your replacement. This may include making arrangements with other service providers, or using other strategies that fit the clients’ needs.

I am an NP-Pediatrics and I provide care to children with complex health issues. Some of my clients are approaching adulthood and I have not been able to find another health care provider to care for them due to their complexity. Can I continue to provide care to these clients until another health care provider can take over?

Yes. In limited circumstances, NPs may provide health care services to clients outside the population group associated with their specialty certificate. This should only happen if they have the knowledge, skill and judgment required, and the decision to provide care is based on a client’s best interest. In your case, continuing to provide care to your clients promotes continuity of care and meets the client’s needs.

NPs who may have to provide health care services to clients outside the population group associated with their specialty certificate, should ensure that clients and other members of the health care team are aware of their specialty certificate.

Outside these unique circumstances, NPs are expected to limit their practice to a client population that is appropriate for the specialty certificate that they hold. For example:

• an NP with an Adult specialty certificate can provide health services to clients who range in age from adolescence to older adulthood
• an NP with a Pediatrics specialty certificate can provide health services to clients who range in age from neonates to late adolescence
• an NP with a Primary Health Care specialty certificate can provide health services to clients of all ages

I am an NP working in a community health clinic. Can I complete a Form 1 for a client?

No. The regulations under the Mental Health Act specify that an Application by Physician for Psychiatric Assessment (Form 1) be completed by a physician.

Furthermore, a Certificate of Involuntary Admission (Form 3) also requires a physician’s assessment and the examining physician’s signature. For this reason, an NP would not be able to admit involuntary clients under the Mental Health Act.

For more information on NP accountabilities, read the Nurse Practitioner practice standard.

I am a nurse practitioner (NP) considering work in a role where I provide virtual assessments and prescribe cannabis to patients located outside Ontario. What should I be aware of and consider before working in this role and performing these activities?

There are different perspectives on providing virtual care that NPs should be aware of; CNO’s, regulatory bodies outside of Ontario and employers’ perspectives.

CNO does not prevent nurses registered in Ontario from providing virtual care to patients in other provinces or countries. In these instances, nurses are responsible for practicing according to the relevant laws in the jurisdiction where their patient is located. If a nurse is providing care to a patient in a different jurisdiction, the nurse must contact the regulator in that jurisdiction to make sure they are complying with their laws and requirements. Some provinces, territories or countries may require nurses to be registered with them in order to provide virtual care.

The employer’s perspective is also very important. It is at the employer’s discretion to determine policies and procedures regarding the scope of roles and responsibilities of their employees. This includes whether nurses they employ can provide virtual care to patients in other jurisdictions, and the type of nursing care they may want their NPs to provide.

Another important consideration is the NP’s authority and competence to prescribe cannabis. NPs have the authority to prescribe medical cannabis. They are accountable for ensuring that medical cannabis is an appropriate evidence-based treatment for their patients. NPs must also have the knowledge, skill and judgment to prescribe safely and competently.

Here are some guiding questions to reflect on as you consider working in this practice environment:

• Do I have the knowledge, skill and judgment to perform these activities?
• Am I able to provide a comprehensive assessment of the patient through virtual care?
• Have I consulted with other nursing regulatory bodies regarding their perspectives on virtual care?
• Have I consulted with my employer and reviewed relevant organizational policies?
• Can the patient’s pharmacist accept a prescription from a nurse practitioner outside of their jurisdiction?
• Have I consulted with my liability protection provider?

As always, NPs are expected to apply the requirements outlined in CNO’s practice standards, Nurse Practitioner and Scope of Practice. You can also refer to the Ask Practice FAQ, Understanding Your Scope of Practice.

For more information on virtual care, refer to CNO’s Virtual Care guideline. See also, the NP Practice Q&A tab on prescribing and administering medication for additional details about Ontario NPs prescribing medical cannabis.

Can I continue to use my educational credentials (e.g., PHCNP) if I resign from CNO?

Yes, you can use your educational or academic credentials as these are not protected titles under the Nursing Act, 1991.

Academic credentials that include terms such as "nurse practitioner" and “NP” (e.g., PHCNP) can be used without registration with CNO, provided that you use the qualifier “resigned”.

Anita Singh, BScN, MScN, PHCNP (resigned).

In Ontario, only nurses registered with CNO can use the titles of nurse, Registered Nurse, Registered Practical Nurse, or any variation, abbreviation or equivalent in another language.

Can I perform point of care testing, such as rapid strep tests and urine dipstick analyses?

Yes. NPs can perform laboratory tests for the purpose of diagnosing and treating their clients. This is authorized under the Laboratory and Specimen Collection Centre Licensing Act.

I write orders such as requisitions for laboratory and diagnostic tests for clients when they are discharged from hospital. What is my accountability in following up with clients in this situation?

As the health professional who ordered the test, you are also accountable for following up, or ensuring there is a reliable system in place for appropriate follow-up. This means that you and the hospital should have a process for reviewing the results from the tests you have ordered and following up with clients.

You can facilitate the safe transfer of accountability by providing a timely discharge summary, including information about tests ordered. To promote continuity of care, you can make sure laboratory and diagnostic requisitions include a request to have test results sent to both yourself and the Primary Health Care provider.

You are accountable for communicating the following information with clients and documenting them:

• the significance of the tests being ordered,
• potential implications of not taking the test,
• what type of follow-up to expect, and
• how they will receive the test results.

You may also want to give a copy of the discharge summary to clients. The accountabilities when ordering tests are outlined in the Nurse Practitioner practice standard.

What is my accountability if a client does not undergo a test that I have ordered?

There is a shared accountability; ultimately, clients make their own decision about whether to undergo a test. You are accountable for ensuring clients have the necessary information to make an informed decision about taking the test. In addition, you are expected to ensure systems are in place to track that you have ordered the test. This enables you to follow up with the client if required. If you learn that your client has not taken the test, it provides you with an opportunity to explore the client’s reasons and engage in additional health teaching. You should document your follow up with the client, including any unsuccessful follow-up attempts if the client does not respond.

Can I apply ultrasound?

NPs can apply ultrasound, which is a controlled act. The forms of energy that NPs are authorized to apply are specified in law.

When applying ultrasound, NPs are accountable to expectations in the practice standards including Nurse Practitioner and Scope of Practice.

Why don't the expectations talk about forms of energy?

You may have noticed that we do not have specific practice expectations related to NPs ordering or applying ultrasound. CNO’s standards and guidelines are broad and principle-based to apply to a variety of NPs working in different roles and practice settings. CNO develops practice standards to outline accountabilities and expectations regardless of the clinical areas or practice settings in which NPs work.

You can read more about developing standards here.

Aside from the practice expectations in CNO's practice standards, Scope of Practice and the Nurse Practitioner, what other practice expectations exist related to applying ultrasound?

Like any other activity or procedure NPs engage in, they are expected to have the knowledge, skill and judgment to apply ultrasound safely, effectively and ethically. In addition to the expectations outlined in the Scope of Practice and the Nurse Practitioner practice standards:

• NPs are engaged in the diagnostic process and develop differential diagnoses through identification, analysis, and interpretation of findings from a variety of sources
• NPs consult with other health care professionals when encountering client care needs beyond the legal scope of NP practice, their individual competence, or when the client would benefit from the expertise of these other health care professional(s)
• Nurses identify required resources (present and future) to manage outcomes before performing a procedure
• Nurses ensure they are competent in both the cognitive and technical aspects of a procedure before performing it
• Nurses maintain competence and refrain from performing activities she/he is not competent in
• Nurses ensure their practice is based on theory and evidence and meets all relevant standards and guidelines
• Nurses ensure their rationale for performing the procedure is based on achieving the best outcomes for the client

For more information about these accountabilities see the Scope of Practice and the Nurse Practitioner practice standards.

Can I order physical restraints?

Whether an NP can order restraints depends on the setting.

The Patient Restraints Minimization Act, 2001 specifies that only a physician or a person specified by regulation can order a restraint.

Only physicians are authorized to order restraints for patients in hospital as there are no regulations under the Patient Restraints Minimization Act that lists other persons.

In long-term care, NPs are authorized to order restraints as they are specifically listed in regulations under the Fixing Long-Term Care Act, 2021.

I noticed there were changes to the diagnostic tests NPs can order and apply. Do I need to complete education before taking on these new authorities?

Some NPs are already performing the new authorities in their practice setting. For others, this is a new activity to integrate into their practice.

As part of continuing competence, NPs should reflect on their practice, identify learning needs, and develop and meet learning goals. Before taking on these or any new authorities, you may identify that you need to complete education or training, and/or learn from an expert in your practice setting.

All nurses are accountable for maintaining competence throughout their career. (See the Scope of Practice standard.)

What authorities do NPs in Ontario have with respect to medical cannabis?

Under section 272(1) of the Cannabis Regulations NPs are authorized to: 

• Provide clients with a “medical document”^[1]
• Issue “written orders”^[2] while practicing in a “hospital”^[3] as defined by the Cannabis Regulations
• Administer cannabis product^[4] to clients, other than cannabis plants or cannabis seeds
• Transfer a cannabis product to clients, other than cannabis plants or cannabis plant seeds (subject to certain restrictions)

NPs who have a therapeutic relationship with the client are authorized to provide medical documents or written orders for cannabis to treat or relieve their condition. NPs are accountable for ensuring that medical cannabis is an appropriate, evidence-based treatment and meets the accountabilities outlined under therapeutic management in the Nurse Practitioner practice standard. 

NPs completing a medical document or written order to authorize the use of cannabis for medical purposes must review the risks, side effects, drug interactions with other medications, cannabis-related conditions, poisonings, safe storage and the importance of obtaining cannabis from a legal source. 

Completing a Medical Document

Under section 273 of the Cannabis Regulations, a medical document must indicate:

• the NP’s full name, professional designation, registration number, and contact information (business address, phone, fax and email, if applicable),
• the address of the location where the client consulted with the NP,
• the province in which the NP is authorized to practice their profession and the registration number assigned by the province to that authorization,
• the client’s full name and date of birth,
• the daily amount of dried cannabis, expressed in grams, that the NP authorizes for the client, and
• the period of use (maximum 1 year), specified as a number of days, weeks or months.

The NP must sign and date the medical document and include a statement confirming the information in the document is correct and complete. The medical document is only valid for the period of use specified within it and must not exceed one year. NPs are recommended to keep a copy of the completed medical document for their records. 

Health Canada monitors misuse of the medical cannabis system in Canada. NPs who authorize medical cannabis may be subject to review and follow-up. NPs must be prepared to provide supporting information such as peer-reviewed data, references, or resources to support their clinical reasoning such as their documentation record. If the NP does not respond to the request or cannot provide information to substantiate the authorized amount, the client’s application may be refused.

To assist NPs who authorize cannabis for their clients, Health Canada has published documents on its website that provide important information on research into the medicinal use of cannabis, dosing and administration, and client information. This includes information on reporting of adverse reactions from the use of cannabis. 

Issuing a Written Order

Under section 274 of the Cannabis Regulations, a written order must be signed and dated by the NP and include the following:

• the NP’s full name, professional designation and registration number,
• the client’s full name who is under the professional treatment of the NP, and
• the daily amount of dried cannabis, expressed in grams, that the NP authorizes for the client. 

Additional Resources:

• Information for Health Care Professionals: Cannabis and the cannabinoids
• Health Canada: Medical use of cannabis
• Canadian Nurses Protective Society: Access to Cannabis for Medical Purposes, what every nurse should know
• Lower-Risk Cannabis Use Guidelines: A Comprehensive Update of Evidence and Recommendations
• Institute for Safe Medication Practices Canada (ISMP): Navigating Cannabis Conversations 
• CNO Ask Practice: Medical Cannabis 

[1] Part 14 of the Cannabis Regulations defines “medical document” as a document provided by an NP to support the use of cannabis for medical purposes.
[2] Part 14 of the Cannabis Regulations defines defines “written order” as a written authorization given by an NP that a stated amount of cannabis be dispensed for the individual named in the authorization. 
[3] The Cannabis Regulations defines “hospital” as a facility that is (a) licensed, approved or designated by a province under the laws of the province to provide care or treatment to individuals suffering from any form of disease or illness; or (b) that is owned or operated by the Government of Canada or the government of a province and that provides health services. NPs must determine if their facility would satisfy the definition of “hospital” within the Cannabis Regulation.
[4] The Cannabis Regulations defines “cannabis product” as cannabis of certain classes of cannabis, including dried cannabis, cannabis oil, fresh cannabis, cannabis plants and cannabis plant seeds — or a cannabis accessory if that accessory contains such cannabis — after it has been packaged and labeled for sale to a consumer at the retail level, but does not include a drug containing cannabis

What are controlled substances and why are they restricted?

A controlled substance is one that is included in Schedule I, II, III, IV or V of the federal Controlled Drugs and Substances Act. Controlled substances are used in healthcare to treat a wide variety of conditions including, but not limited to, pain, anxiety, epilepsy and sleep disorders. They include opioids, benzodiazepines, amphetamines, sedatives, anti-emetics and hormonal therapies, among others. Controlled substances are restricted because they present a high risk for potential misuse, addiction and diversion.

Can NPs prescribe controlled substances?

Only NPs who have successfully completed College approved controlled substances education are authorized to prescribe controlled substances in Ontario. For more information about the education, read Q&As: Controlled Substances Education Requirement.

Is controlled substances content part of NP program curriculum?

“Yes. Controlled substances content is integrated in the curriculum for all Ontario NP programs. Students enrolled in Ontario NP programs will meet the required controlled substances content and do not have to complete a standalone course.

Members and applicants who don’t have this content in their NP program can take Council-approved controlled substances courses to gain the foundational competencies that are unique to controlled substances, and meet their education requirement set out in regulation.

Are there any controlled substances that NPs can’t prescribe?

Yes, regulations under the federal law prohibit NPs from prescribing the following controlled substances:

• opium (such as opium and belladonna suppository)
• coca leaves (such as cocaine)

How can I tell if an NP is authorized to prescribe controlled substances?

You can use the College’s register “Find a Nurse” to check whether an NP is authorized to prescribe controlled substances. NPs who are not authorized to prescribe controlled substances are identified on the register as “Entitled to practice. Cannot prescribe controlled substances until specialized education is completed.”

Can NPs prescribe methadone and diacetylmorphine?

Under the Controlled Drug and Substances Act (CDSA) NPs have the authority to prescribe and administer methadone without an exemption. NPs also have the authority to prescribe diacetylmorphine.

Only NPs who have successfully completed CNO approved controlled substances education are authorized to prescribe controlled substances in Ontario, this includes methadone, buprenorphine and diacetylmorphine. Additional resources are also available to support NPs continuing competence and clinical decision making.

Activities associated with controlled substances are high risk. As with any other activity or procedure NPs engage in, they are expected to have the knowledge, skill and judgment to prescribe methadone and diacetylmorphine in a safe, competent and ethical manner. NPs are expected to understand the unique risks associated with prescribing any controlled substance and incorporate relevant evidence-informed strategies to mitigate these risks.

NPs are also expected to meet the accountabilities outlined in the Nurse Practitioner practice standard and ensure they have the competence to prescribe methadone, buprenorphine and diacetylmorphine.

Additional resources:
Controlled Substances – Resources and References

You must meet the expectations for prescribing controlled substances outlined in the Nurse Practitioner practice standard. These include prescribing a quantity of controlled substances to be dispensed that balances the need to reassess and monitor the client with the risk of harm that may result if the client runs out of medication. NPs providing episodic care should prescribe the minimum amount necessary until the client can be assessed by their regular care provider.

I’m involved in procuring medications for my practice setting. Are there any legal requirements around reporting theft of controlled substances?

There are legal requirements under the Controlled Drugs and Substances Act related to record-keeping and reporting theft of these medications. You must report the loss or theft of controlled substances to Health Canada’s Office of Controlled Substances within 10 days.

I’m an NP that is not authorized to prescribe controlled substances. What do I do if I determine a client requires a prescription for a controlled substance?

NPs can expect to encounter clients requiring prescriptions for controlled substances, since many medications are controlled substances. You should plan for this anticipated client care need by establishing strategies consistent with College standards and guidelines. You should also work with your employer to ensure you have access to resources for meeting client needs. In this case, the resource you need is the ability to refer to a health professional such as an NP or physician authorized to prescribe controlled substances. The client’s prescription must be filled out by the authorized prescriber in a manner that is consistent with their regulatory obligations.

NPs who are not authorized to prescribe controlled substances must not taper a controlled substance or renew a prescription for a controlled substance as these are considered prescribing.

If you commonly encounter clients in your practice that require controlled substances you should consider completing the education requirement that would authorize you to prescribe controlled substances. As expected for any activity, you may have additional learning needs you have to meet, relevant to your setting and client population.

I’m an NP who is not authorized to prescribe controlled substances. I assessed a client and determined that she needs treatment with a controlled substance. The physician I work with agreed with my findings and proposed a treatment plan. Can I complete this prescription based on the outcome of my consultation with the physician?

No. Consulting with a physician does not give you the legal authority to prescribe any medication. The authority to prescribe medication comes from the legislation. Therefore, in this case the physician should be asked to prescribe the controlled substance. Physicians have their own professional accountabilities, which may also require them to personally assess the client.

I’m an NP interested in developing a policy related to weaning clients off high doses of narcotics. Does CNO have guidelines to support this?

CNO does not have guidelines related to weaning patients off high doses of narcotics. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings. When determining what sources of information are most appropriate to inform your nursing practice, use your clinical judgment to assess the individual care needs of each patient, the appropriateness of the nursing practice and the practice environment you are working in.

CNO's controlled substances resources and references page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or patient population. You are accountable for using the best evidence to inform your clinical decisions.

NPs are accountable for taking appropriate action to resolve or minimize the risk of harm to a patient from a medication adverse reaction (from the Medication practice standard). Implementing a policy that supports weaning patients of high doses of narcotics is one example of meeting this expectation. With patient interest and safety in mind, you are expected to work with your interdisciplinary colleagues to identify gaps in available policies, procedures and processes, and if needed, develop them.

I’m an NP and I work in a walk-in clinic. I’m concerned that patients are drug-shopping to divert controlled substances. How do I spot this behaviour and manage any increased patient pressure?

First, you should read the Nurse Practitioner practice standard to know your accountabilities when faced with this types of situation. For example, the practice standard says NPs are accountable for incorporating evidence-informed strategies for assessing, managing and monitoring the risks of misuse, addiction and diversion.

Additional resources are also available on CNO's Controlled Substances: Resources and References page to support NPs continuing competence and clinical decision making.

The Nurse Practitioner practice standard says NPs need to identify when collaboration, consultation and referral are necessary for safe, competent and comprehensive client care. So, you may want to consult another healthcare professional to benefit from their expertise.

I’m an NP and I have patients who are addicted to controlled substances. I want to help. Does CNO have guidelines to support my practice?

The Nurse Practitioner practice standard states that NPs are accountable for using strategies to reduce risk of harm involving controlled substances, including medication misuse, addiction and diversion.

CNO does not have guidelines specific to treating patients who are addicted to controlled substances. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings.

CNO's Controlled Substances: Resources and References page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or patient population. You are accountable for using the best evidence to inform your clinical decisions. With patient interest and safety in mind, you are expected to work with your interdisciplinary colleagues to identify gaps in available policies, procedures and processes, and if needed, develop them.

I’m a new NP working in an emergency department and I treat a variety of clients. I would like information for my prescribing practice (e.g., information related to cancer pain, chronic pain, managing withdrawal symptoms, dealing with opioid tolerant clients). Does the College have guidelines to support this?

NPs are accountable for implementing evidence-informed therapeutic interventions (from the NP practice standard).

CNO does not have guidelines related to the clinical areas you are inquiring about. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings. However, we recognize that to meet the expectation in the Nurse Practitioner practice standard that says NPs are accountable for implementing evidence-informed therapeutic intervention, NPs need resources to inform this area of their practice. We have developed a page that points NPs to a variety of resources related to controlled substances, including content that will support the areas you mentioned in your question.

The controlled substances resource page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or client population.

My client is not compliant with the plan of care and is refusing urine screening to monitor medication compliance. I am concerned about prescribing controlled substances in light of this. What should I do?

As an NP, you are responsible for monitoring the client’s response to the prescribed substance and for assessing, managing and monitoring the risks of misuse, addiction and diversion. You are also responsible for implementing strategies to mitigate these risks, and should only perform procedures or activities when you have access to the appropriate client information.

Several factors can contribute to conflict between an NP and a client. For example, this can occur if an NP judges or misunderstands a client (e.g., the client may feel the NP is not listening to, or respecting, their values, opinions or beliefs). NPs may need to reflect on and modify their communication style to meet the needs of the client and find the best possible solution in any complex nurse-client situation.

Ultimately, if the challenges with your client continue and place the client at risk, then you are accountable for acknowledging when there is a diminished therapeutic relationship and for requesting a transfer of care.

For more information on the accountabilities mentioned above, read the Therapeutic Nurse Client Relationship practice standard, Nurse Practitioner practice standard and Conflict Prevention and Management practice guideline.

I have been managing a client with complex addiction issues. My client is pushing for prescriptions that are not in their best interest and I’ve grown increasingly concerned about my personal safety. How do I manage this?

The College does not expect nurses to put their lives or personal safety at risk when caring for clients. As the primary NP, consider if you are the most appropriate care provider for that client and/or whether you need to refer to, or consult, an expert such as an addictions specialist or psychiatrist. For example, consider if you have the knowledge, skill and judgment to continue treating this client. Also, NPs are accountable for identifying when collaboration, consultation and referral are necessary for safe, competent and comprehensive client care.

Employers also have accountabilities under the Occupational Health and Safety Act – they are accountable for establishing a safe work environment and minimizing real or potential risk to employees and clients alike.

The College encourages nurses to work collaboratively with their employers, as well as colleagues, to mitigate real or potential threats. If needed, they should develop policies, procedures and processes that are specific to the practice setting and driven by client interests and safety. 

Where can I find information about Ontario’s Narcotics Strategy, and the Narcotics Monitoring System?

Information about Ontario's Narcotics Strategy and the Narcotics Safety and Awareness Act, 2010 can be found on the Ministry of Health's website. As part of the Narcotics Strategy, the province has established the Narcotics Monitoring System (NMS) to monitor the prescribing and dispensing of controlled substances. Although its name implies the monitoring of narcotics, the NMS monitors all controlled substances as well as opioids that are not controlled substances (such as medications containing Tramadol). The main purpose of the NMS is to examine drug-use patterns to inform harm reduction strategies and education initiatives, and improve prescribing and dispensing practices related to monitored drugs. If illegal activity or professional misconduct is suspected, the Ministry may report information from the NMS to law enforcement bodies and regulatory colleges.

Can I dispense medications that are controlled drugs and substances?

Yes, you can dispense a controlled substance that you prescribed or that was ordered by a physician or dentist with whom you work. The Nurse Practitioner and the Medication practice standards describe the practice expectations for public protection when dispensing medication.

How will this authority affect medical assistance in dying?

Medical assistance in dying protocols may require controlled substances. This regulation change may enable NPs to provide medical assistance in dying protocols (in accordance with legal requirements). See Guidance on Nurses’ Role in Medical Assistance in Dying for a description of legal and professional requirements.

How often am I required to complete approved controlled substances education?

This is a one-time requirement to gain foundational competencies that are unique to controlled substances. You may have other learning needs related to controlled substances. As part of commitment to continuing competence and quality improvement, you are expected to engage in practice reflection to identify learning needs, and set and achieve learning goals.

Can I dispense medications that are controlled drugs and substances?

Yes, you can dispense a controlled substance that you prescribed or that was ordered by a physician or dentist with whom you work. The Nurse Practitioner and the Medication practice standards describe the practice expectations for public protection when dispensing medication.

I notice that I may be required to put an “identification number” on a medication that I dispense. What is the identification number?

The identification number is assigned to track medications from the point of procurement to the point they are provided to a client. The purpose of an identification number is to trace a medication back to the manufacturer. In the event of safety concerns (e.g., a medication recall), the identification number enables health professionals to follow up with clients appropriately.

You should consult your employer about whether this tracking system exists in your practice setting and how to obtain the identification number. If such a system does not exist, you should advocate for measures to ensure safe medication practices. If you are self-employed, you are expected to establish your own tracking system. The practice expectations for public protection when dispensing medication are described in the Nurse Practitioner practice standard.

Why is the drug manufacturer’s name required on the label of a medication I dispense? What if this information is not available to me?

Including the manufacturer’s name is another mechanism used for tracking medication. Depending on your practice setting, this information may not be readily available to you. For example, if you are dispensing medication from a supply that is stocked by a pharmacist, the medication may have been re-packaged, and therefore, while this information is available to the pharmacist, it is not available to you. If you do not have access to this information, then you are not required to include it.

When an NP is compounding a cream for topical application, the NP is expected to have the manufacturer’s original packaging for the various substances used in the compound. Therefore, when compounding, you must include the manufacturer’s name on the label if the compound is being dispensed to a client.

Is it a conflict of interest for NPs who prescribe a medication to also dispense or sell that medication?

No. The College has developed specific conflict-of-interest provisions to reduce the risk of NPs finding themselves in a position of conflict. For example, NPs cannot charge “dispensing fees” or obtain a profit from the sale of a medication.

NPs cannot obtain any benefit as a result of prescribing, dispensing or selling medication. A “benefit” is defined as any financial or non-financial incentive, whether direct or indirect, that conflicts with an NP’s professional or ethical duty to a client. NPs are expected to base treatment decisions on best available evidence, clinical judgment and client needs. NPs do not prescribe a particular medication because it is available for sale in the practice setting.

The practice expectations for public protection are described in the Nurse Practitioner practice standard.

Can NPs sell medication? Can I ask an administrative assistant to conduct the financial transaction associated with selling medication?

Yes, NPs can sell medication with the exception of controlled substances. NPs are prohibited from selling controlled substances. Before you sell a medication, you are accountable for assessing the client to determine that at least one of the following circumstances exists:

• the client does not have reasonable access to a pharmacy
• the client would not otherwise receive the medication
• the client does not have the financial resources to otherwise obtain the medication, or
• the medication is sold as part of a health promotion initiative.

NPs cannot charge more than the actual cost of the medication, neither for personal financial gain nor to account for overhead or any other expense incurred.

Although NPs cannot delegate the sale of medication, if the above circumstances are met, an administrative assistant may conduct the financial transaction, which is the only one aspect involved in a sale.

For further information about the practice expectations for public protection when selling medication, see the Nurse Practitioner practice standard.

Can I apply defibrillation or electrocoagulation?

No. Until the necessary regulations under the Regulated Health Professions Act, 1991 are put in place by government, you must continue to use delegation for applying forms of energy, such as defibrillation or electrocoagulation. For further information about forms of energy, click on the Practice Resources tab.

CNO will advise members through its website, its Quality Practice newsletter and The Standard when the regulatory amendments are approved and take effect.

Can I perform transvenous cardiac pacing?

No. Although transvenous cardiac pacing is not explicitly listed as a form of energy under the Regulated Health Professions Act, 1991 (RHPA), the College’s interpretation is that this procedure falls under “cardiac pacemaker therapy,” which is listed. Until the necessary regulations under the RHPA are put in place by government, you must continue to use delegation for applying forms of energy. For further information about forms of energy, click on the Practice Resources tab.

CNO will advise members through its website, its Quality Practice newsletter and The Standard when the regulatory amendments are approved and take effect.

Do I require a ‘consulting’ physician?

There is no longer a legal requirement for NPs to establish and maintain a consultative relationship with a physician; therefore, you do not require a ‘consulting’ physician. However, the consultation standards have not changed, in that you are expected to consult physicians and other health professionals when you encounter client care needs beyond the legal scope of NP practice or your individual competencies. Furthermore, some employers require NPs to have a consulting physician (see question below).

To make consulting possible, you would establish a network of other health professionals, as appropriate, to meet client care needs. If your current consulting arrangements with physicians meet this objective, then you should continue with those arrangements.

The practice expectations for public protection when providing interprofessional care and consultation are described in the Nurse Practitioner practice standard.

I work in a long-term care home. Why is my employer asking for the name of a ‘consulting’ physician with whom I work?

Notwithstanding the information provided in the question above, certain employers may have specific requirements related to NP consultation. For example, regulations of the Fixing Long-Term Care Act, 2021 may require an NP to tell the long-term care home the name of the physician with whom the NP has a consultative relationship. NPs should consult their employers to determine whether specific requirements exist.

As a nurse, I am already performing point-of-care testing in my setting. What do these changes mean for my current practice?

These changes may mean different things for you, depending on your employer and practice setting. This is because each practice setting is governed by different legislation and each employer has its own unique policies and procedures.

Nurses are encouraged to work with their employers, including their laboratory department, to determine how these changes may impact their practice.

Here are some guiding questions to ask your employer to support these discussions:

• How do the recent changes in point-of-care testing regulations impact various procedures in our practice setting?
• What tests do you support me performing as an RN, RPN or NP?
• What policies and resources support me performing this procedure?

Related links:

• Scope of Practice
• Ask Practice FAQ on Understanding Your Scope of Practice (cno.org)

I am an NP, what are my accountabilities when performing point-of-care tests?

As outlined in the Nurse Practitioner practice standard, when performing point-of-care tests, NPs are accountable to:

• ensure they have the necessary resources available to perform the test appropriately and safely, and to manage potential outcomes associated with performing the test;
• ensure an appropriate environment to perform the test;
• procure samples properly;
• interpret the findings / results accurately;
• refer the patient for more comprehensive testing (e.g., laboratory test, ultrasound, etc.) if there is uncertainty about the accuracy or clarity of the result, or if further investigation is required; and
• verify that there are reliable quality assurance mechanisms in place to ensure the proper and safe functioning of the equipment they use, and not using equipment when concerns have been identified.

As of July 1, 2022, NPs will be able to order CTs and MRIs. As an NP, how will these changes affect my current practice?

These changes may mean different things for you, depending on your employer, practice setting and the care needs of your patient population.

NPs have an accountability to determine how these changes affect their current practice processes in delivering safe patient care. NPs are encouraged to work with their employers, including their radiology department, to determine how these changes may impact their practice.

Here are some guiding questions to ask your employer to support these discussions:

• How does this impact my role and responsibilities as an NP?
• What policies support the performance of this activity?
• Do you foresee any barriers to NPs ordering CTs and MRIs in this practice setting? If so, how can these be managed?

Can an NP also order contrast media?

Our colleagues at the College of Medical Radiation and Imaging Technologists of Ontario (CMRITO) advised us that the specialist (that is, staff in the radiology department) determines whether the investigation requires the use of contrast media. This determination by the specialist includes identifying the type of contrast, dosage and contraindications. This process provides the necessary authorization to the medical radiation and imaging technologists (MRITs) performing the procedure on the patient.

The specialist’s decision regarding the use of contrast media is informed by the clinical information provided by the ordering NP, such as patient history, the clinical reason for the CT or MRI examination and the differential diagnosis. It is important that the NP include as much relevant clinical information as possible in the imaging requisition to support the specialist’s informed decision-making to support safe and efficient patient care delivery.

NPs are encouraged to discuss their setting-specific process to order contrast media with their radiology department, including the physicians and imaging and radiation technologists for further insight.

What are my accountabilities when ordering and performing procedures as an NP?

NPs order and perform procedures when they have a therapeutic professional relationship with the patient. When ordering or performing any procedure, including those involving the application of a form of energy, NPs are accountable to:

• determine that the procedure is warranted
• determine that the procedure is a safe and effective intervention for the patient
• explain to patients the details of, and rationale for, the procedure as appropriate
• explain to patients what they can expect from the procedure
• monitor the patient responses during the procedure
• interpret the findings of the procedure accurately or consultation if there are any questions about the accuracy of the interpretation of the findings/results
• incorporate findings or outcomes of the procedure into treatment plans
• communicate clinically significant results and findings, and the implications of those results, to patients and other health professionals as appropriate
• verify that there are reliable quality assurance mechanisms in place to ensure the proper and safe functioning of the equipment they use, and not using equipment when concerns have been identified

In addition, when performing any procedure themselves — including those that involve the application of a form of energy — NPs are accountable to:

• ensure they have the necessary resources available to perform the procedure appropriately and safely, and to manage potential outcomes associated with the procedure
• ensure that the patient has been prepared appropriately; and
• ensure an appropriate environment for conducting the procedure.

It is important to note that ordering nuclear medicine testing remains prohibited.

Related links:

• Ask Practice FAQ on Understanding Your Scope of Practice (cno.org) and Scope of Practice standard
• Nurse Practitioner practice standard
• Nurse Practitioners to order CTs and MRIs | Oral and Maxillofacial Surgeons to order MRIs · CMRITO Portal

Do NPs have the competencies to order CTs and MRIs tests?

Yes, NPs already order diagnostic tests including x-rays and ultrasound. As outlined in CNO’s Entry-to-Practice Competencies for Nurse Practitioners, entry-level competencies, which are the knowledge, skills and judgment required to support safe practice, include competencies related to ordering diagnostic testing, which includes diagnostic imaging such as CTs and MRIs. These competencies are integrated into foundational NP programs (foundational programs are approved by CNO).

For example, competencies include that NPs must:

• inform the client of the rationale for ordering diagnostic tests
• order and/or perform screening and diagnostic investigations using best available evidence to support or rule out differential diagnoses
• integrate laboratory and diagnostic results with history and physical assessment findings
• analyze and interpret multiple sources of data, including results of diagnostic and screening tests, health history, and physical examination
• interpret the results of screening and diagnostic investigations using evidence-informed clinical reasoning

With any activity or procedure, nurses are accountable for maintaining and continually improving their competence. Depending on how this change is implemented in an NP’s practice setting, NPs may identify individual learning needs which they need to meet in order to safety carry out this or any other activity. Continuing competence and ongoing Quality Assurance is an accountability for all nurses. 

Related links:

• Entry-to-Practice Competencies for Nurse Practitioners

My colleagues have asked if other regulations and policies have been updated to ensure clinicians involved in the process are paid?

CNO asked the government this question and they shared the following on June 10, 2022: "physicians who submit claims to OHIP for services ordered by NPs will be paid for both the technical and professional components of the service. Independent Health Facilities that submit claims to OHIP for services ordered by nurse practitioners will be paid.”