When a doctor writes standing orders telling a nurse to give certain medications under specified conditions, can the nurse legally carry them out? And does it make a difference whether the medications are controlled substances?
Plain-English summary
The Coordinator of the Regulatory Section in the Office of the Assistant Secretary for Alcohol and Drug Abuse asked the AG a practical operational question about North Carolina's collaborative nurse-physician practice rules in 1979. Doctors at substance abuse treatment programs wrote standing orders saying things like "if a patient presents with X condition, give Y medication." The Coordinator wanted to know two things. First, could a registered nurse legally execute such standing orders without separate physician contact at the moment of administration? Second, did the answer change if the medication on the standing order was a controlled substance (a Schedule II opioid, for example)?
The AG split the questions and answered them separately.
On the standing-orders question, the AG concluded that an RN could carry out standing orders, but only if the RN had been formally approved by the Board of Medical Examiners under the joint Board of Medical Examiners and Board of Nursing regulations codified as 32E NCAC. The pathway was statutory and regulatory: G.S. 90-18 defined the practice of medicine broadly; G.S. 90-18(14) carved out a narrow exception for nursing practice and for RNs performing medical acts under rules jointly developed by the two boards. The joint regulations (32E NCAC .0001 et seq.) defined an "approved registered nurse" as one functioning under physician supervision and approved by the Board of Medical Examiners by training and experience to perform specified medical tasks. The regulations expressly contemplated standing orders as part of physician supervision. Only an approved RN could carry out a physician's standing orders.
On the controlled-substances question, the AG concluded that even an approved RN could not carry out standing orders involving controlled substances. The joint regulations at 32E NCAC .0003 included an explicit exception in their prescribing rule: "Prescriptions, except controlled substances, may upon specific orders of the supervising physician . . . be written and issued by such registered nurse for the use by patients of drugs which are not included in the formulary." The regulations went on to state that "no prescription shall be written or issued by such registered nurse for any drugs which are specified as controlled substances under the Federal Controlled Substances Act." The carve-out was complete: an approved RN had no authority to prescribe or dispense controlled substances, full stop.
The practical implication for a substance abuse program in 1979 was straightforward. Standing orders for non-controlled medications could be implemented by approved RNs. Standing orders for controlled substances (opioid maintenance medications, benzodiazepines, certain stimulants) required a physician to be in the loop at the prescribing moment, not just at the standing-order-drafting moment.
Currency note
This opinion was issued in 1979. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here.
The North Carolina Nurse Practice Act, the joint board regulations, and the framework for advanced practice registered nurses have all been substantially modified since 1979. North Carolina now recognizes nurse practitioners as a distinct advanced practice category with their own prescribing authority, and the rules governing controlled substance prescribing by APRNs have been the subject of repeated statutory and regulatory revision. The "approved registered nurse" terminology and the specific 32E NCAC subchapter cited here have largely been replaced or restructured. Anyone working with current standing-order or controlled-substance issues should consult the current Board of Nursing and Board of Medical Examiners (now Medical Board) regulations, the current Nurse Practice Act, and federal DEA registration requirements rather than this 1979 opinion. Federal controlled-substance prescribing rules have themselves been substantially restructured since 1979.
Historical context: what the AG concluded
The opinion is methodologically clean. It starts with the practice-of-medicine definition, walks through the nursing carve-out, and applies the joint board regulations to the two questions.
The practice-of-medicine definition. G.S. 90-18 defined the practice of medicine as "diagnosing or attempting to diagnose, treating or attempting to treat . . . or prescribing for or administering to, or professing to treat any human ailment, physical or mental or any physical injury to or deformity of any other person." Read literally, almost any clinical care activity falls within that definition. The General Assembly therefore had to carve out specific exceptions for other professionals (nurses, dentists, optometrists, podiatrists, and so on). Without those exceptions, any non-physician clinical act would be unauthorized practice of medicine.
The nursing carve-out. G.S. 90-18(14) carved out two distinct activities: (a) the practice of nursing by an RN engaged in the practice of nursing, and (b) the performance of acts otherwise constituting medical practice by an RN "when performed in accordance with rules and regulations developed by a joint subcommittee of the Board of Medical Examiners and the Board of Nursing and adopted by both boards." The second clause is where the standing-orders authority comes from. It is not in the nursing-practice clause; it is in a separate medical-acts clause requiring joint board rulemaking.
The joint board regulations. Subchapter 32E of the North Carolina Administrative Code, titled "Approval of Registered Nurse Performing Medical Acts," was the joint product of the two boards. It defined an "approved registered nurse" as one functioning under physician direction or supervision and approved by the Board of Medical Examiners as qualified by training and experience to perform the listed functions. The regulations described supervision (32E NCAC .0001) as including "review of the registered nurses' practice, between conferences incorporating chart review and co-signing records to document accountability: prescribing within that practice setting, standing orders and drug protocol for interval between conferences to be part of this regular review and documentation." Standing orders, by name, were part of how the regulations envisioned the supervision relationship.
The AG's reading was that, because standing orders are part of the supervision framework the regulations specifically address, only an RN approved under the regulations could carry them out. An unapproved RN, even a clinically competent one, was outside the framework and so could not legally implement standing orders.
The controlled substances carve-out. 32E NCAC .0003 spelled out the prescribing rule: "When the proposed medical functions of a registered nurse include prescribing of drugs, the supervising (backup) physician and the registered nurse shall review the formulary approved by the North Carolina Board of Nursing and the Board of Medical Examiners of the State of North Carolina, and shall acknowledge in the application to the board that they are familiar with the formulary, and that the formulary will be a part of the incorporated in the approved standing orders." The regulation then created an explicit exception: prescriptions "except controlled substances" could be written by an approved RN on specific physician orders, and "no prescription shall be written or issued by such registered nurse for any drugs which are specified as controlled substances under the Federal Controlled Substances Act." The two prohibitions stack: the RN cannot write a controlled-substance prescription on a physician's specific order, and the RN also cannot write a controlled-substance prescription pursuant to a standing order. Both paths to controlled-substance access for an RN-mediated workflow are closed.
The AG read these together as a complete prohibition. The clinical operational consequence: standing orders for substance abuse treatment medications had to be implemented by a different mechanism if the medications were federally controlled (Schedule II through V). The most common workflow would have been physician contact at the prescribing moment (telephone order or in-person assessment) rather than a pre-issued standing order.
For an alcohol and drug abuse treatment program in 1979, the operational takeaway was: maintain approved-RN status documentation for every RN expected to carry out standing orders; identify any standing orders that involve controlled substances and route those through a physician at prescribing time rather than through the standing-order mechanism; and confirm that the joint formulary the regulations require is in place and current.
Common questions
What is a standing order?
A pre-issued physician order that directs the nurse to take a specified action (give a specified medication, perform a specified procedure) when a specified clinical condition is observed. The point is to allow the nurse to act without contacting the physician again at the moment of action. Standing orders are common in emergency departments, intensive care units, substance abuse treatment programs, and many outpatient settings.
Who was the "approved registered nurse" the AG referred to?
A registered nurse who functioned under physician supervision and was specifically approved by the Board of Medical Examiners under 32E NCAC as qualified by training and experience to perform medical tasks. The approval was case-specific to the practice setting; an application to the board described the proposed functions, the supervising physician, and the formulary.
Could any RN carry out standing orders in 1979?
No. The opinion is explicit that only an approved RN could legally carry out standing orders. An RN who had not gone through the joint-board approval process was outside the regulatory framework, and the medical-acts carve-out in G.S. 90-18(14) did not apply.
What was the controlled-substances rule?
Even an approved RN could not write or issue a prescription for any controlled substance under the Federal Controlled Substances Act. The joint board regulations were direct: "no prescription shall be written or issued by such registered nurse for any drugs which are specified as controlled substances." The prohibition applied whether the request came as a physician standing order or as a specific physician order.
Why didn't standing orders for controlled substances work?
Two reasons. First, the joint regulations' formulary structure was the platform for RN prescribing, and controlled substances were excluded from the formulary by the regulations themselves. Second, federal controlled-substance law in 1979 placed prescribing authority at the level of the physician (DEA registrant) rather than the nurse, and the state regulations were consistent with that federal allocation.
What did substance abuse programs do for controlled medications in 1979?
The operational workaround was physician contact at prescribing time. The nurse would assess the patient, contact the physician, the physician would give a telephone or in-person order, and the nurse would carry out the order under physician direction. The order was specific to the patient and the moment, not a pre-issued standing order.
Did the joint regulations require a formulary?
Yes. 32E NCAC .0003 required the supervising physician and the approved RN to review the formulary approved jointly by the Board of Nursing and the Board of Medical Examiners and to acknowledge familiarity in their application. The formulary was the menu of drugs the RN could prescribe under specific physician orders. Controlled substances were excluded from that menu.
Could the approved RN prescribe non-formulary drugs?
Yes, under one path. The regulations allowed prescriptions for non-formulary drugs "upon specific orders of the supervising physician, given before the prescription is issued." That is the same physician-contact-at-prescribing-time path the workaround for controlled substances would use, just for non-controlled non-formulary drugs.
Background and statutory framework
The opinion is grounded in three sources: the practice-of-medicine definition, the nursing carve-out, and the joint board regulations.
G.S. 90-18 (practice of medicine). The statutory definition is broad: diagnosing, treating, prescribing, administering, or professing to treat human ailments. Almost all hands-on clinical work fits the definition.
G.S. 90-18(14) (nursing carve-out). Two clauses. The first authorizes the practice of nursing by an RN, which is governed by the Nurse Practice Act and the Board of Nursing's regulations. The second authorizes RNs to perform "acts otherwise constituting medical practice" under joint Board of Medical Examiners and Board of Nursing regulations. The second clause is the source of the medical-acts authority the opinion focuses on. It requires both boards to participate in rulemaking and is the legal foundation for the approved-RN framework.
Subchapter 32E NCAC ("Approval of Registered Nurse Performing Medical Acts"). The joint product of the two boards. Three operative regulations the opinion discusses:
32E NCAC .0001 defines the "approved registered nurse" and describes the supervision relationship, including the role of standing orders within physician supervision. Supervision is described as a recurring review process with chart review, conference, and co-signature documenting accountability.
32E NCAC .0003 governs prescribing authority. It requires the supervising physician and the approved RN to review the joint board formulary together. It allows prescriptions for non-formulary drugs on specific physician orders, "except controlled substances." It expressly prohibits issuance of any prescription for drugs specified as controlled substances under the Federal Controlled Substances Act.
Federal Controlled Substances Act. The federal framework for controlled-substance regulation. Substances are scheduled according to medical use and abuse potential, and federal DEA registration is required for legal prescribing. The state regulations' carve-out of controlled substances tracks the federal framework: the state was not authorizing what federal law did not permit.
Citations
- G.S. 90-18 (practice of medicine definition)
- G.S. 90-18(14) (nursing carve-out and joint Board of Medical Examiners and Board of Nursing rulemaking authority)
- 32E NCAC .0001 (definition of approved registered nurse; description of supervision and standing orders)
- 32E NCAC .0003 (formulary requirement; controlled-substance carve-out; prohibition on RN-issued controlled-substance prescriptions)
- Federal Controlled Substances Act (federal scheduling and prescribing framework)
Source
Original opinion text
Requested By: F. E. Epps, Coordinator of Regulatory Section, Office of Assistant Secretary for Alcohol and Drug Abuse
Questions:
May standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, be carried out by a registered nurse?
May those standing orders be carried out by a registered nurse when the medications described are controlled substances?
Conclusions:
Standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, may be carried out by a registered nurse if that registered nurse has been approved by the Board of Medical Examiners to perform medical acts.
A registered nurse may not carry out standing orders of a physician which involve controlled substances even if that registered nurse has been approved by the Board of Medical Examiners to perform medical acts.
The primary question for determination is whether or not standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, may be carried out by a registered nurse.
G.S. 90-18 defines practicing medicine as "diagnosing or attempting to diagnose, treating or attempting to treat . . . or prescribing for or administering to, or professing to treat any human ailment, physical or mental or any physical injury to or deformity of any other person."
Any act which comes within this definition may be done only by a licensed physician unless the act is specifically authorized by another statute or regulation.
Certain acts are specifically authorized when they are performed by a registered nurse.
G.S. 90-18(14) specifically excepts from the definition of "practicing medicine": "The practice of nursing by a registered nurse engaged in the practice of nursing and the performance of acts otherwise constituting medical practice by a registered nurse when performed in accordance with rules and regulations developed by a joint subcommittee of the Board of Medical Examiners and the Board of Nursing and adopted by both boards."
These rules and regulations are codified as Subchapter 32E of the North Carolina Administrative Code, and are entitled "Approval of Registered Nurse Performing Medical Acts." These regulations define "registered nurse" as a "registered nurse who is functioning and performing medical tasks at the direction of or under the supervision of a physician licensed to practice medicine in North Carolina, and which nurse is approved by the board defined in the regulations as the Board of Medical Examiners of the State of North Carolina as being qualified by training and experience to perform the functions and tasks outlined in the application at the direction of or under the supervision of a physician."
Standing orders are specifically mentioned in the description of what is meant by the term "under the supervision of a physician." The regulations state that "The backup physician shall be available on a regularly scheduled bases for . . . review of the registered nurses' practice, between conferences incorporating chart review and co-signing records to document accountability: prescribing within that practice setting, standing orders and drug protocol for interval between conferences to be part of this regular review and documentation." (32E NCAC .0001)
Thus, standing orders of physicians as described herein may be carried out by registered nurses who have been approved by the Board of Medical Examiners under the terms of the regulations and it is the opinion of this Office that the intent of the regulations is that only registered nurses approved by the board may carry out standing orders of a physician.
A secondary question to be determined is whether or not standing orders of a physician which name controlled substance as the medication to be given once it has been determined that certain conditions exist may be carried out by a registered nurse. The regulations state:
"When the proposed medical functions of a registered nurse include prescribing of drugs, the supervising (backup) physician and the registered nurse shall review the formulary approved by the North Carolina Board of Nursing and the Board of Medical Examiners of the State of North Carolina, and shall acknowledge in the application to the board that they are familiar with the formulary, and that the formulary will be a part of the incorporated in the approved standing orders. Changes in the formulary are to be approved by the board. In regard to changes, the approved formulary may include any over-the-counter or non-prescription drug.
Prescriptions, except controlled substances, (Emphasis ours) may upon specific orders of the supervising physician, given before the prescription is issued, be written and issued by such registered nurse for the use by patients of drugs which are not included in the formulary. . . . However, no prescription shall be written or issued by such registered nurse for any drugs which are specified as controlled substances under the Federal Controlled Substances Act." (32 E NCAC .0003)
Thus, it is the opinion of this Office that a registered nurse may not carry out standing orders which involve controlled substances.
Rufus L. Edmisten
Attorney General
Ann Reed
Special Deputy Attorney General