How Many Nurse Practitioners Can a Physician Supervise in Georgia

In Georgia, one physician can supervise up to four advanced practice registered nurses (APRNs) under nurse protocol agreements at any one time. That cap rises to eight agreements at accredited facilities that use evidence-based clinical practice guidelines, though only four of those APRNs may be actively supervised simultaneously. Several practice settings, including licensed hospitals and public health departments, are exempt from the numerical limit altogether. The rules come from O.C.G.A. 43-34-25 and Georgia Composite Medical Board Rule 360-32-.04.

The Default Four-APRN Limit

Board Rule 360-32-.02 sets the baseline: a physician may enter into nurse protocol agreements with no more than four APRNs at any one time. The count is combined with physician assistants. Job descriptions supervising PAs under O.C.G.A. 43-34-103 count against the same four-person cap, so a physician who already supervises two PAs can take on only two APRNs before hitting the ceiling.¹

The limit reflects how much oversight Georgia expects from a delegating physician. Each protocol agreement carries its own chart review, consultation, and annual review obligations, and the state treats four as the outer edge of what a single doctor can realistically maintain.

The Expanded Limit at Accredited Facilities

Physicians practicing at facilities accredited by a Board-approved organization, such as the Joint Commission, can enter protocol agreements with up to eight APRNs if the facility maintains evidence-based clinical practice guidelines. The catch: even with eight agreements on paper, the physician may only actively supervise four APRNs at any one time.²

At these accredited locations, the physician must document review of at least 10 percent of the APRN’s medical records. That review may be conducted electronically or on-site.¹

Settings With No Numerical Cap

Subsection (g) of the statute exempts a list of practice settings from the numerical limit entirely. If the APRN works in one of these settings, the physician can supervise as many APRNs as the operational structure requires:

Licensed hospitals
County boards of health
The Georgia Department of Public Health
Free health clinics
Community service boards
Federally qualified health centers
Certain other nonprofit and public entities listed in the statute

The exemption exists for a practical reason. Hospitals, public health departments, and safety-net clinics need physician oversight structures that don’t bottleneck at four APRNs per doctor.³

Who Qualifies as a Delegating Physician

Before the numerical cap even comes into play, the physician has to be eligible to delegate to a given APRN. Georgia law defines “physician” for these purposes as someone licensed to practice medicine in the state whose principal practice location is either inside Georgia or, if outside the state, within 50 miles of the location where the APRN will use the protocol.³ The 50-mile radius is what allows some cross-border supervision near Alabama, Tennessee, South Carolina, and Florida.

The physician and the APRN must also work in a comparable specialty area or field. A cardiologist cannot sign a protocol delegating primary care duties to a family nurse practitioner if the specialties don’t align. Subsection (c) of the statute builds this matching requirement in to keep the delegating physician genuinely qualified to oversee the APRN’s clinical work.³

What Each Supervisory Slot Actually Requires

The four-APRN cap is only meaningful if you understand what one slot involves. Every nurse protocol agreement must be in writing, signed by both parties, and available for review by the Board of Nursing (for the APRN) or the Composite Medical Board (for the physician) upon written request. Both parties must review, revise, or update the agreement at least once a year.³

The agreement has to name identifying information for both parties (including DEA numbers where applicable), a designated backup physician for consultation, the specific delegated acts the APRN may perform, the number of refills allowed, which diagnostic studies or imaging tests can be ordered, documentation requirements, a chart review schedule, a patient follow-up provision, and the applicable standard of care for the patient population.²

Chart Review Obligations

Board Rule 360-32-.02(7) sets minimum chart review standards for each supervisory relationship:

The physician (or designated backup) must review and sign 100 percent of patient records for patients who received controlled substance prescriptions, at least quarterly. Separately, the statute requires the physician to evaluate or examine every patient receiving a controlled substance on at least a quarterly basis.
The physician must review and sign 100 percent of records involving an adverse outcome, within 30 days of discovering it.
The physician must review and sign at least 10 percent of all other patient records, at minimum once per year.

Multiply those obligations by four APRNs, and it becomes clear why Georgia caps the number.¹

Immediate Consultation

Every protocol agreement must include a provision for “immediate consultation,” meaning the delegating physician is reachable by phone or other telecommunications whenever the APRN needs guidance. If the primary physician is unavailable, a designated backup physician who has agreed to the protocol’s terms must be accessible.³

Penalties for Exceeding the Limit or Failing to Supervise

Signing a fifth non-exempt nurse protocol agreement, or holding four agreements without actually maintaining the supervision each requires, both expose the physician to discipline. Under O.C.G.A. 43-34-8, the Georgia Composite Medical Board can impose:

Fines up to $3,000 per violation, plus additional fines to reimburse the Board’s investigation costs
License suspension for a definite or indefinite period
License revocation
Probation with conditions
Practice restrictions
Mandatory continuing education or competency examinations
Public or private reprimand

The Board can also withhold formal judgment while placing the physician on conditional terms, then vacate the probation if the physician fails to comply.⁴

Delegating professional responsibilities to someone not authorized to receive them is separately disciplinable under Board Rule 360-3-.05. A physician who signs protocol agreements but skips annual reviews, ignores the chart review percentages, or remains unreachable for consultation faces the same range of penalties as more overt misconduct.⁵ The APRN’s license is on the line as well, since the Board of Nursing regulates the nurse side of the same agreement.

Putting the Numbers Together

For most Georgia physicians in private practice, the practical answer is four APRNs (counting any PAs already under supervision). Physicians at Joint Commission or comparably accredited facilities that follow evidence-based guidelines can hold up to eight protocol agreements, with four actively supervised at a time. Hospital-based physicians, and those supervising APRNs in public health departments, community service boards, federally qualified health centers, and the other exempt settings, have no numerical ceiling at all. Whatever the count, each agreement stands or falls on the specialty match, the 50-mile rule, the annual review, and the chart review and consultation obligations that make the supervision real.

1
Cornell Law Institute. Georgia Code of Regulations 360-32-.02 – Requirements for Nurse Protocol Agreements Pursuant to Code Section 43-34-25
2
Georgia Secretary of State. Georgia Code Chapter 360-32 – Nurse Protocol Agreements Pursuant to O.C.G.A. Section 43-34-25
3
Justia. Georgia Code 43-34-25 – Delegation of Certain Medical Acts to Advanced Practice Registered Nurse
4
FindLaw. Georgia Code Title 43 Professions and Businesses 43-34-8
5
Georgia Secretary of State. Georgia Code Chapter 360-3 – Investigations and Discipline