Chapter 28. Delegation of Acts by an Advanced Practice Registered Nurse
Regulation .01 Scope.LinkCopy Citation
A.
This chapter governs the delegation of nursing or other technical tasks by an advanced practice registered nurse to an assistant not otherwise authorized under Health Occupations Article, Annotated Code of Maryland.
B.
This chapter may not be construed:
(1)
As establishing the licensure, certification, or registration of assistants by the Board;
(2)
To apply to an individual who is licensed, certified, or registered by a health occupations regulatory board, or health occupation students, acting pursuant to Health Occupations Article, Annotated Code of Maryland; and
(3)
To mean that this chapter overrides, or is to be used in lieu of, more stringent regulations, policies, and procedures established by State licensure or certification requirements.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Advanced practice registered nurse (APRN)” has the meaning stated in Health Occupations Article, §8-101, Annotated Code of Maryland.
(2)
“Assistant” means an individual:
(a)
To whom only routine nursing and technical tasks are delegated by an advanced practice registered nurse;
(b)
Who is trained as defined in §B(12) of this regulation; and
(c)
Who is not licensed, certified, registered, or otherwise authorized by law by the Board, or any other State health occupations board, to practice any health occupation in the State.
(3)
“Asynchronous telehealth interaction” has the meaning stated in Health Occupations Article, §1-1001, Annotated Code of Maryland.
(4)
“Board” means the Maryland Board of Nursing.
(5)
“Delegating APRN” means an advanced practice registered nurse who directs an assistant to perform nursing and technical tasks.
(6)
“Direct supervision” means oversight exercised by a delegating APRN who is:
(a)
Personally treating the patient; and
(b)
In the physical presence of the patient and the assistant.
(7)
Mechanical Act.
(a)
“Mechanical act” means an act which does not require professional judgment, medical or pharmaceutical training, or discretion.
(b)
“Mechanical act” does not include:
(i)
Selecting a drug;
(ii)
Labeling;
(iii)
Measuring or calculating dosages;
(iv)
Substituting one drug for another, including substituting a generic or brand drug for the prescribed drug;
(v)
Substituting one dosage form of a drug for another;
(vi)
Altering the route of administration; or
(vii)
Counseling patients.
(8)
“On-site supervision” means oversight exercised by a delegating APRN who is present at the same site as the assistant and the patient and is:
(a)
Able to be immediately available in person during the assistant’s performance of a delegated act;
(b)
In the context of a synchronous telehealth interaction, able to be immediately available via secure telecommunications technology to the telehealth visit during the assistant’s performance of a delegated act; or
(c)
In the context of an asynchronous telehealth interaction, able to review the assistant’s work and interact with the assistant before communication with the patient.
(9)
“Site” means any facility or location, including those defined in Health-General Article, §§19-114 and 19-3B-01(b), Annotated Code of Maryland, used for the delivery of health care services.
(10)
“Synchronous telehealth interaction” has meaning stated in Health Occupations Article, §1-1001, Annotated Code of Maryland.
(11)
“Technical task” means a routine clinical act or task that does not require clinical or nursing judgment and is performed with supervision as specified within this chapter.
(12)
“Trained” means possessing the knowledge, skills, and abilities, as determined by the delegating APRN, to perform delegated nursing and technical tasks.
Regulation .03 Standards for Delegation.LinkCopy Citation
A.
An APRN who delegates shall:
(1)
Assess the risk to the patient and the outcome of the delegated acts;
(2)
Delegate only those nursing and technical tasks that are customary to the practice of an APRN;
(3)
Delegate only those nursing and technical tasks for which the assistant has been trained;
(4)
Be responsible for the acts of the assistant;
(5)
Supervise the assistant in accordance with this chapter; and
(6)
If authorized to dispense prescription medication under Health Occupations Article, Title 8, Annotated Code of Maryland, perform a final check of the prescription medication before it is provided to the patient.
B.
The responsibility for the delegated act cannot be transferred from the delegating APRN to another APRN, or to another licensed health care provider that is authorized to delegate clinical and technical tasks, without:
(1)
The expressed consent of the other APRN or licensed health care provider; and
(2)
Informing the assistant.
Regulation .04 Scope of Delegation to an Assistant.LinkCopy Citation
A.
An APRN may not delegate nursing and technical tasks to an assistant which shall, by law or regulation, be performed only by an individual that is required to be licensed, certified, registered, or otherwise recognized pursuant to any State laws.
B.
An APRN may delegate nursing and technical tasks, consistent with national guidelines for nursing delegation established by the National Council of State Boards of Nursing and the approved policies and procedures of the site, in the following categories:
(1)
Surgical technical tasks that the delegating APRN directly orders while present and personally performing the surgery in the same surgical field; and
(2)
Nonsurgical technical tasks while the assistant is under the delegating APRN’s direct supervision or on-site supervision.
C.
Except as provided in §§B(1) and D of this regulation, an APRN shall provide at minimum on-site supervision when delegating nursing or technical tasks to an assistant, including, but not limited to, the following:
(1)
Patient preparation for physical examination;
(2)
Patient history interview;
(3)
Collecting and processing specimens, such as performing phlebotomy, inoculating culture media, pregnancy tests; dipstick and microscopic urinalysis, and microbiology including rapid streptococcal testing and throat cultures;
(4)
Preparing and performing laboratory tests that the APRN is satisfied the assistant is trained and qualified to perform under State and Clinical Laboratory Improvement Amendments regulations;
(5)
Clinical tests including, but not limited to:
(a)
Application of tuberculin skin tests;
(b)
Electrocardiography;
(c)
Administering basic pulmonary function tests; and
(d)
Visual field tests;
(6)
Transmitting prescriptions to a pharmacy;
(7)
Preparing and administering oral drugs;
(8)
Preparing and administering injections limited to intradermal, subcutaneous, and intramuscular within the deltoid, gluteal, or vastus lateralis muscles including small amounts of local anesthetics;
(9)
Establishing a peripheral intravenous line; and
(10)
Injecting fluorescein-like dyes for retinal angiography.
D.
When delegating injecting intravenous drugs or contrast materials to an assistant, an APRN shall provide direct supervision.
E.
An APRN who is authorized to dispense prescription medication under Health Occupations Article, Title 8, Annotated Code of Maryland may delegate only mechanical acts involved in dispensing a drug.
F.
An APRN may not delegate to an assistant any act that requires the exercise of clinical judgment by an APRN, including, but not limited to:
(1)
Conducting physical examinations;
(2)
Administering any form of anesthetic agent or agent of conscious sedation other than topical anesthetics or small amounts of local anesthetics;
(3)
Initiating independently any form of treatment, except for cardiopulmonary resuscitation or other forms of emergency treatment authorized to be performed by non-clinicians under State law;
(4)
Establishing a diagnosis or giving clinical advice; and
(5)
Providing physical therapy.
Regulation .05 Prohibited Conduct and Penalties.LinkCopy Citation
A.
An assistant acting beyond the scope of this chapter may be:
(1)
Considered to be engaged in the unlicensed practice of nursing, advanced practice registered nursing, or any other health occupation recognized by the State; and
(2)
Subject to all applicable fines and penalties in accordance with Health Occupations Article, §§8-701—8-711, Annotated Code of Maryland and applicable regulations, or any other applicable provision of Health Occupations Article, Annotated Code of Maryland.
B.
A delegating APRN, through either act or omission, facilitation, or otherwise enabling or forcing an assistant to practice beyond the scope of this chapter, may be subject to discipline as set forth in Health Occupations Article, §8-316, Annotated Code of Maryland.
C.
A delegating APRN may not:
(1)
Require an assistant to perform a delegated nursing or technical task; or
(2)
Permit an assistant to delegate any act to another individual.
Regulation .06 Enforcement.LinkCopy Citation
The Board shall conduct any necessary investigation regarding the failure to comply with the requirements of Health Occupations Article, Title 8, Annotated Code of Maryland and this chapter, and it may refer any complaint or investigation to any other appropriate licensing or regulatory authority in accordance with applicable laws and regulations.
Chapter annotations
Authority: Health Occupations Article, §§8-205 and 8-6A-02, Annotated Code of Maryland
History: Effective date:
History: Regulations .01 — .06 adopted as an emergency provision effective August 26, 2025 (52:20 Md. R. 999); adopted permanently effective October 27, 2025 (52:21 Md. R. 1024)