chapter157

Texas Medical Board, Texas Physician Assistant Board, Texas State Board of Acupuncture Examiners - Safeguarding the public through professional accountability

CHAPTER 157.

AUTHORITY OF PHYSICIAN TO DELEGATE CERTAIN MEDICAL ACTS SUBCHAPTER

A. GENERAL PROVISIONS

§ 157.001. General Authority of Physician to Delegate

(a) A physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate if, in the opinion of the delegating physician:

(1) the act:

(A) can be properly and safely performed by the person to whom the medical act is delegated;

(B) is performed in its customary manner; and

(2) the person to whom the delegation is made does not represent to the public that the person is authorized to practice medicine.

(b) The delegating physician remains responsible for the medical acts of the person performing the delegated medical acts.

(1) an act constitutes the practice of medicine, not inconsistent with this chapter; and

(2) a medical act may be properly or safely delegated by physicians.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.002. General Delegation of Administration and Provision of Dangerous Drugs

(a) In this section:

(1) "Administering" means the direct application of a drug to the body of a patient by injection, inhalation, ingestion, or any other means.

(2) "Provision" means the supply of one or more unit doses of a drug, medicine, or dangerous drug.

(b) A physician may delegate to any qualified and properly trained person acting under the physician's supervision the act of administering or providing dangerous drugs in the physician's office, as ordered by the physician, that are used or required to meet the immediate needs of the physician's patients. The administration or provision of the dangerous drugs must be performed in compliance with laws relating to the practice of medicine and state and federal laws relating to those dangerous drugs.

(c) A physician may also delegate to any qualified and properly trained person acting under the physician's supervision the act of administering or providing dangerous drugs through a facility licensed by the Texas State Board of Pharmacy, as ordered by the physician, that are used or required to meet the immediate needs of the physician's patients. The administration of those dangerous drugs must be in compliance with laws relating to the practice of medicine, professional nursing, and pharmacy and state and federal drug laws. The provision of those dangerous drugs must be in compliance with:

(1) laws relating to the practice of medicine, professional nursing, and pharmacy;

(2) state and federal drug laws; and

(3) rules adopted by the Texas State Board of Pharmacy.

(d) In the provision of services and the administration of therapy by public health departments, as officially prescribed by the Texas Department of Health for the prevention or treatment of specific communicable diseases or health conditions for which the Texas Department of Health is responsible for control under state law, a physician may delegate to any qualified and properly trained person acting under the physician's supervision the act of administering or providing dangerous drugs, as ordered by the physician, that are used or required to meet the needs of the patients. The provision of those dangerous drugs must be in compliance with laws relating to the practice of medicine, professional nursing, and pharmacy. An order for the prevention or treatment of a specific communicable disease or health condition for which the Texas Department of Health is responsible for control under state law may not be inconsistent with this chapter and may not be used to perform an act or duty that requires the exercise of independent medical judgment.

(e) The administration or provision of the drugs may be delegated through a physician's order, a standing medical order, a standing delegation order, or another order defined by the board.

(f) Subsections (b) and (c) do not authorize a physician or a person acting under the supervision of a physician to keep a pharmacy, advertised or otherwise, for the retail sale of dangerous drugs, other than as authorized under Section 158.003, without complying with the applicable laws relating to the dangerous drugs.

(g) A drug or medicine provided under Subsection (b) or (c) must be supplied in a suitable container labeled in compliance with applicable drug laws. A qualified and trained person, acting under the supervision of a physician, may specify at the time of the provision of the drug the inclusion on the container of the date of the provision and the patient's name and address.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.003. Emergency Care

The authority to delegate medical acts to a properly qualified person as provided by this subchapter applies to emergency care provided by emergency medical personnel certified by the Texas Department of Health.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.004. Delegation Regarding Certain Care for Newborns; Liability

(a) It is the policy of this state that the prevention of ophthalmia neonatorum in newborn infants is of paramount importance for the protection of the health of the children of this state.

(b) The authority to delegate medical acts to a midwife under Chapter 203 applies to the possession and administration of eye prophylaxis for the prevention of ophthalmia neonatorum.

(c) A physician who issues a standing delegation order to a midwife under Chapter 203 is not liable in connection with an act performed under that standing delegation order if the midwife provides proof of documentation under that chapter before the order is issued.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.005. Performance of Delegated Act Not Practicing Without Medical License

A person to whom a physician delegates the performance of a medical act is not considered to be practicing medicine without a license by performing the medical act unless the person acts with knowledge that the delegation and the action taken under the delegation is a violation of this subtitle.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.006. Limitation on Board Rules Regarding Delegation

The board shall promote a physician's exercise of professional judgment to decide which medical acts may be safely delegated by not adopting rules containing, except as absolutely necessary, global prohibitions or restrictions on the delegation of medical acts.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.007. Applicability of Other Laws

An act delegated by a physician under this chapter must comply with other applicable laws.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

SUBCHAPTER B. DELEGATION TO ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS § 157.051. Definitions

In this subchapter:

(1) "Advanced practice nurse" has the meaning assigned to that term by Section 301.152. The term includes an advanced nurse practitioner.

(2) "Carrying out or signing a prescription drug order" means completing a prescription drug order presigned by the delegating physician, or the signing of a prescription by a registered nurse or physician assistant after that person has been designated to the board by the delegating physician as a person delegated to sign a prescription.

(3) "Physician assistant" means a person who holds a license issued under Chapter 204.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.052. Prescribing at Sites Serving Certain Medically Underserved Populations

(a) In this section:

(1) "Health manpower shortage area" means:

(A) an urban or rural area of this state that:

(i) is not required to conform to the geographic boundaries of a political subdivision but is a rational area for the delivery of health service;

(ii) the secretary of health and human services determines has a health manpower shortage; and

(iii) is not reasonably accessible to an adequately served area;

(B) a population group that the secretary of health and human services determines has a health manpower shortage; or

(C) a public or nonprofit private medical facility or other facility that the secretary of health and human services determines has a health manpower shortage, as described by 42 U.S.C. Section 254e(a)(1).

(2) "Medically underserved area" means:

(A) an area in this state with a medically underserved population;

(B) an urban or rural area designated by the secretary of health and human services as an area in this state with a shortage of personal health services or a population group designated by the secretary as having a shortage of those services, as described by 42 U.S.C. Section 300e 1(7); or

(i) demographics specific to this state;

(ii) geographic factors that affect access to health care; and

(iii) environmental health factors.

(3) "Registered nurse" means a registered nurse recognized by the Board of Nurse Examiners as having the specialized education and training required under Section 301.152.

(4) "Site serving a medically underserved population" means:

(A) a site located in a medically underserved area;

(B) a site located in a health manpower shortage area;

(D) a public health clinic or a family planning clinic under contract with the Texas Department of Human Services or the Texas Department of Health;

(E) a site located in an area in which the Texas Department of Health determines there is an insufficient number of physicians providing services to eligible clients of federal, state, or locally funded health care programs; or

(F) a site that the Texas Department of Health determines serves a disproportionate number of clients eligible to participate in federal, state, or locally funded health care programs.

(b) After making a determination under this section that a site serves a medically underserved population, the Texas Department of Health shall publish notice of its determination in the Texas Register and provide an opportunity for public comment in the manner provided for a proposed rule under Chapter 2001, Government Code.

(c) At a site serving a medically underserved population, a physician licensed by the board may delegate to a registered nurse or physician assistant acting under adequate physician supervision the act of administering, providing, or carrying out or signing a prescription drug order, as authorized by the physician through a physician's order, a standing medical order, a standing delegation order, or another order or protocol as defined by the board. The authority of a physician to delegate the carrying out or signing of prescription drug orders is limited to dangerous drugs.

(d) An advertisement for a site serving a medically underserved population must include the name and business address of the supervising physician for the site.

(e) Physician supervision is adequate for the purposes of this section if a delegating physician:

(1) is responsible for the formulation or approval of the physician's order, standing medical order, standing delegation order, or other order or protocol, and periodically reviews the order and the services provided patients under the order;

(2) is on-site to provide medical direction and consultation at least once every 10 business days during which the advanced practice nurse or physician assistant is on-site providing care;

(3) receives a daily status report from the advanced practice nurse or physician assistant on any problem or complication encountered; and

(4) is available through direct telecommunication for consultation, patient referral, or assistance with a medical emergency.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.053. Prescribing at Physician Primary Practice Sites

(a) In this section, "primary practice site" means:

(1) the practice location of a physician at which the physician spends the majority of the physician's time;

(2) a licensed hospital, a licensed long-term care facility, or a licensed adult care center where both the physician and the physician assistant or advanced practice nurse are authorized to practice;

(3) a clinic operated by or for the benefit of a public school district to provide care to the students of that district and the siblings of those students, if consent to treatment at that clinic is obtained in a manner that complies with Chapter 32, Family Code;

(4) the residence of an established patient; or

(5) another location at which the physician is physically present with the physician assistant or advanced practice nurse.

(b) At a physician's primary practice site, a physician licensed by the board may delegate to a physician assistant or an advanced practice nurse acting under adequate physician supervision the act of administering, providing, or carrying out or signing a prescription drug order as authorized through a physician's order, a standing medical order, a standing delegation order, or another order or protocol as defined by the board. Providing a drug and carrying out or signing a prescription drug order under this section is limited to dangerous drugs.

(c) Physician supervision of the carrying out and signing of prescription drug orders must conform to what a reasonable, prudent physician would find consistent with sound medical judgment but may vary with the education and experience of the particular advanced practice nurse or physician assistant. A physician shall provide continuous supervision, but the constant physical presence of the physician is not required.

(d) An alternate physician may provide appropriate supervision on a temporary basis as defined and established by board rule.

(e) A physician's authority to delegate the carrying out or signing of a prescription drug order is limited to:

(1) three physician assistants or advanced practice nurses or their full-time equivalents practicing at the physician's primary practice site or at an alternate practice site under Section 157.0541; and

(2) the patients with whom the physician has established or will establish a physician-patient relationship.

(f) For purposes of Subsection (e)(2), the physician is not required to see the patient within a specific period.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999. Amended by Acts 2001, 77th Leg., ch. 112, § 1, eff. May 11, 2001.

§ 157.054. Prescribing at Facility-Based Practice Sites

(a) A physician licensed by the board may delegate, to one or more physician assistants or advanced practice nurses acting under adequate physician supervision whose practice is facility-based at a licensed hospital or licensed long-term care facility, the administration or provision of a drug and the carrying out or signing of a prescription drug order if the physician is:

(1) the medical director or chief of medical staff of the facility in which the physician assistant or advanced practice nurse practices;

(2) the chair of the facility's credentialing committee;

(3) a department chair of a facility department in which the physician assistant or advanced practice nurse practices; or

(4) a physician who consents to the request of the medical director or chief of medical staff to delegate the carrying out or signing of a prescription drug order at the facility in which the physician assistant or advanced practice nurse practices.

(b) A physician's authority to delegate under Subsection (a) is limited as follows:

(1) the delegation must be made under a physician's order, standing medical order, standing delegation order, or another order or protocol developed in accordance with policies approved by the facility's medical staff or a committee of the facility's medical staff as provided by the facility bylaws;

(2) the delegation must occur in the facility in which the physician is the medical director, the chief of medical staff, the chair of the credentialing committee, or a department chair;

(3) the delegation may not permit the carrying out or signing of prescription drug orders for the care or treatment of the patients of any other physician without the prior consent of that physician;

(4) delegation in a long-term care facility must be by the medical director and is limited to the carrying out and signing of prescription drug orders to not more than three advanced practice nurses or physician assistants or their full-time equivalents;

(5) a physician may not delegate at more than one licensed hospital or more than two long-term care facilities unless approved by the board; and

(6) the authority of a physician to delegate the carrying out or signing of a prescription drug order under this section is limited to dangerous drugs.

(d) An alternate physician may provide appropriate supervision on a temporary basis as defined and established by board rule.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.0541. Prescribing at Alternate Sites

(a) In this section, "alternate site" means a practice site:

(1) where services similar to the services provided at the delegating physician's primary practice site are provided; and

(2) located within 60 miles of the delegating physician's primary practice site.

(b) At an alternate site, a physician licensed by the board may delegate to an advanced practice nurse or physician assistant, acting under adequate physician supervision, the act of administering, providing, or carrying out or signing a prescription drug order as authorized through a physician's order, a standing medical order, a standing delegation order, or another order or protocol as defined by the board. The authority of a physician to delegate the carrying out or signing of prescription drug orders under this section is limited to dangerous drugs.

(1) is on-site with the advanced practice nurse or physician assistant at least 20 percent of the time;

(2) reviews at least 10 percent of the medical charts at the site; and

(3) is available through direct telecommunication for consultation, patient referral, or assistance with a medical emergency.

(d) An alternate physician may provide appropriate supervision to an advanced practice nurse or physician assistant under this section on a temporary basis as provided by board rule.

(e) The combined number of advanced practice nurses and physician assistants to whom a physician may delegate under this section and at a primary practice site under Section 157.053 may not exceed three physician assistants or advanced practice nurses or the full-time equivalent of three physician assistants or advanced practice nurses.

Added by Acts 2001, 77th Leg., ch. 112, § 2, eff. May 11, 2001.

§ 157.0542. Board Waiver of Delegation Requirements

Text of section effective until September 1, 2005 (a) On determining that the conditions of Subsection (b) have been met, the board may waive or modify any of the site or supervision requirements for a physician to delegate the carrying out or signing of prescription drug orders to an advanced practice nurse or physician assistant under Sections 157.052, 157.053, 157.054, and 157.0541, or under board rules. The board may not waive the limitation on the number of primary or alternate practice sites at which a physician may delegate the carrying out or signing of prescription drug orders or the number of advanced practice nurses or physician assistants to whom a physician may delegate the carrying out or signing of prescription drug orders.

(b) The board may grant a waiver under Subsection (a) if the board determines that:

(1) the practice site where the physician is seeking to delegate prescriptive authority is unable to meet the requirements of this chapter or board rules or compliance would cause an undue burden without a corresponding benefit to patient care;

(2) safeguards exist for patient care and for fostering a collaborative practice between the physician and the advanced practice nurses and physician assistants; and

(3) if the requirement for which the waiver is sought is the amount of time the physician is on-site, the frequency and duration of time the physician is on-site when the advanced practice nurse or physician assistant is present is sufficient for collaboration to occur, taking into consideration the other ways the physician collaborates with the advanced practice nurse or physician assistant, including at other sites.

(c) The board shall establish procedures for granting waivers under this section. At a minimum, the procedures must include a process for providing, if the board denies a waiver, a written explanation for the denial and identifying modifications that would make the waiver acceptable and a process for revoking, suspending, or modifying a waiver previously granted. The process for revoking, suspending, or modifying a waiver must include notice and an opportunity for a hearing. The board may probate an order to revoke, suspend, or modify a waiver.

(d) The board shall appoint an advisory committee to review and make recommendations on applications for waivers under this section. Each committee member must be actively practicing as a physician, an advanced practice nurse, or a physician assistant in collaborative practices under which the advanced practice nurse or physician assistant is authorized by the physician to sign or carry out prescription drug orders under this subchapter. The committee consists of 15 members appointed as follows:

(1) five advanced practice nurses appointed from a list of persons recommended by professional associations representing advanced practice nurses;

(2) five physician assistants appointed from a list of persons recommended by professional associations representing physician assistants; and

(3) five physicians appointed from a list of persons recommended by professional associations representing physicians.

(e) The advisory committee shall recommend whether to grant a waiver after making the determinations required of the board under Subsection (a). The board may grant a waiver only if the committee recommends that the waiver be granted, unless the board determines good cause exists to grant a waiver the committee does not recommend.

(f) The advisory committee may recommend that the board approve a waiver with modifications.

(g) An advisory committee recommendation of the approval of a waiver, with or without modifications, requires a vote of at least:

(1) three advanced practice nurse committee members;

(2) three physician assistant committee members; and

(3) three physician committee members.

(h) This section expires September 1, 2005.

Added by Acts 2001, 77th Leg., ch. 112, § 2, eff. May 11, 2001.

§ 157.055. Orders and Protocols

A protocol or other order shall be defined in a manner that promotes the exercise of professional judgment by the advanced practice nurse and physician assistant commensurate with the education and experience of that person. Under this section, an order or protocol used by a reasonable and prudent physician exercising sound medical judgment:

(1) is not required to describe the exact steps that an advanced practice nurse or a physician assistant must take with respect to each specific condition, disease, or symptom; and

(2) may state the types or categories of medications that may be prescribed or the types or categories of medications that may not be prescribed.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.056. Prescription Information

The following information must be provided on each prescription subject to this subchapter:

(1) the patient's name and address;

(2) the drug to be dispensed;

(3) directions to the patient regarding the taking of the drug and the dosage;

(4) the intended use of the drug, if appropriate;

(5) the name, address, and telephone number of the physician;

(6) the name, address, telephone number, and identification number of the registered nurse or physician assistant completing or signing the prescription drug order;

(7) the date; and

(8) the number of refills permitted.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.057. Additional Implementation Methods

The board may adopt additional methods to implement:

(1) a physician's prescription; or

(2) the delegation of the signing of a prescription under a physician's order, standing medical order, standing delegation order, or other order or protocol.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.058. Delegation to Certified Registered Nurse Anesthetist

(a) In a licensed hospital or ambulatory surgical center, a physician may delegate to a certified registered nurse anesthetist the ordering of drugs and devices necessary for the nurse anesthetist to administer an anesthetic or an anesthesia-related service ordered by the physician.

(b) The physician's order for anesthesia or anesthesia-related services is not required to specify a drug, dose, or administration technique.

(c) Pursuant to the physician's order and in accordance with facility policies or medical staff bylaws, the nurse anesthetist may select, obtain, and administer those drugs and apply the medical devices appropriate to accomplish the order and maintain the patient within a sound physiological status.

(d) This section shall be liberally construed to permit the full use of safe and effective medication orders to use the skills and services of certified registered nurse anesthetists.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.059. Delegation Regarding Certain Obstetrical Services

(a) In this section, "provide" means to supply, for a term not to exceed 48 hours, one or more unit doses of a controlled substance for the immediate needs of a patient.

(b) A physician may delegate to a physician assistant offering obstetrical services and certified by the board as specializing in obstetrics or an advanced practice nurse recognized by the Board of Nurse Examiners as a nurse midwife the act of administering or providing controlled substances to the physician assistant's or nurse midwife's clients during intrapartum and immediate postpartum care.

(c) The physician may not delegate the use of a prescription sticker or the use or issuance of an official prescription form under Section 481.075, Health and Safety Code.

(d) The delegation of authority to administer or provide controlled substances under Subsection (b) must be under a physician's order, medical order, standing delegation order, or protocol that requires adequate and documented availability for access to medical care.

(e) The physician's orders, medical orders, standing delegation orders, or protocols must require the reporting of or monitoring of each client's progress, including complications of pregnancy and delivery and the administration and provision of controlled substances by the nurse midwife or physician assistant to the clients of the nurse midwife or physician assistant.

(f) The authority of a physician to delegate under this section is limited to:

(1) three nurse midwives or physician assistants or their full-time equivalents; and

(2) the designated facility at which the nurse midwife or physician assistant provides care.

(g) The controlled substance must be supplied in a suitable container that is labeled in compliance with the applicable drug laws and must include:

(1) the patient's name and address;

(2) the drug to be provided;

(3) the name, address, and telephone number of the physician;

(4) the name, address, and telephone number of the nurse midwife or physician assistant; and

(5) the date.

(h) This section does not authorize a physician, physician assistant, or nurse midwife to operate a retail pharmacy as defined under Subtitle J.

(i) This section authorizes a physician to delegate the act of administering or providing a controlled substance to a nurse midwife or physician assistant but does not require physician delegation of:

(1) further acts to a nurse midwife; or

(2) the administration of medications by a physician assistant or registered nurse other than as provided by this section.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

§ 157.060. Physician Liability for Delegated Act

Unless the physician has reason to believe the physician assistant or advanced practice nurse lacked the competency to perform the act, a physician is not liable for an act of a physician assistant or advanced practice nurse solely because the physician signed a standing medical order, a standing delegation order, or another order or protocol authorizing the physician assistant or advanced practice nurse to administer, provide, carry out, or sign a prescription drug order.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.

SUBCHAPTER C. DELEGATION TO PHARMACISTS § 157.101. Delegation to Pharmacist

(a) In this section, "pharmacist" has the meaning assigned by Section 551.003.

(b) A physician may delegate to a properly qualified and trained pharmacist acting under adequate physician supervision the performance of specific acts of drug therapy management authorized by the physician through the physician's order, standing medical order, standing delegation order, or other order or protocol as defined by board rule.

(1) is responsible for the formulation or approval of the physician's order, standing medical order, standing delegation order, or other order or protocol and periodically reviews the order or protocol and the services provided to a patient under the order or protocol;

(2) has established a physician-patient relationship with each patient who is provided drug therapy management by a delegated pharmacist;

(3) is geographically located so as to be able to be physically present daily to provide medical care and supervision;

(4) receives, as appropriate, a periodic status report on each patient, including any problem or complication encountered; and

(5) is available through direct telecommunication for consultation, assistance, and direction.

(d) This section does not restrict the use of a preestablished health care program or restrict a physician from authorizing the provision of patient care by use of a preestablished health care program if the patient is institutionalized and the care is to be delivered in a licensed hospital with an organized medical staff that has authorized standing delegation orders, standing medical orders, or protocols.

(e) This section does not limit, expand, or change any provision of law relating to therapeutic drug substitution or administration of medication, including Section 554.004.

(f) The board by rule shall establish the minimum content of a written order or protocol. The order or protocol may not permit the delegation of medical diagnosis.

Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.