“... tx.us , for the proper forms.
Please visit Chapter 192 in the Board Rules for the complete regulations.
New: Inspections of registered OBA locations in Texas.
In order that we may ensure compliance with Board Rule 192 regarding the provision of anesthesia services in o ... ”
“... ncy operations. Pursuant to Texas Government Code Chapter 656, TMB provides employees various training programs in order to perform their job duties and tuition assistance for eligible employees. For more information, click on the policy link below:
TMB Training and Education Programs Policy
Other ... ”
“... rerequisite for licensure. (See Board Rules, Chapter 183.)
Tick-Borne Disease Information
Lyme Disease Information (CDC)
TICK TEXAS (Dept. of State Health Services)
Tick-borne Diseases (Dept. of State Health Services)
Zika Virus Resources
Zika in Texas (Dept. of State Health Services)
... ”
“... conduct as defined by the Texas Occupations Code Chapter 164.052(a)(5).
Any physician who wishes to change the professional name under which he/she practices must first satisfy certain formalities and documentation. Any physician who is found to be using a name, other than the one that the phy ... ”
“... prodol, but not including suboxone.
Please visit Chapter 195 of the Board rules for the complete regulations.
Board Rules
”
“To ensure compliance with state law and Chapter 195 of the Board rules, TMB utilizes audits, inspections, and investigations.
The requirements of each of these methods are described fully in Board Rule 195.5. These methods are used to determine and verify if a clinic needs to be registered, is ... ”
“... ed States or other regulatory agency.
See Chapter 166.3 in the Board Rules for additional information.
To return to practice from emeritus retired status, a physician must obtain approval of the Board after submitting a written request. If a physician has been on any official reti ... ”
“... Board in accordance with the requirements of Chapter 1003 of the Texas Health and Safety Code, and 22 Texas Administrative Code §198.6.
An Investigational Review Board (IRB) overseeing clinical trials of investigational stem cell treatments shall submit an annual report to t ... ”
“... he United States or other regulatory agency.
See Chapter 185.28 in the Board Rules for additional information.
To return to practice from emeritus retired status, a physician assistant must obtain approval of the Board after submitting a written request. If a physician assistant has been on any off ... ”
“... raphic regions of the state as further defined in Chapter 191 of Board Rules.
Each committee consists of seven members: three physician members who are doctors of medicine (M.D.), one physician member who is a doctor of osteopathic medicine (D.O.) and three public members. They are appointed to seve ... ”
“... as required by the Medical Physics Practice Act, Chapter 602, Occupations Code.
Medical Physicist Licensure Advisory Committee Member Listing & Terms
What is a medical physicist?
A Medical Physicist is an individual who assures the correct quality, quantity, and placement of radi ... ”
“... ical education, as indicated in Title 22, Part 9, Chapter 194, Subchapter A, Rule 194.7 (c).
To request voluntary charity care status, complete and return the voluntary charity care request form (link below) to Board for approval before the expiration date of the current certificate. R ... ”
“... ed in Texas Administrative Code Title 25, Part 1, Chapter 194, Subchapter A, Rule 194.16.
The hardship exemption applicant shall not allow a person who is not an MRT, LMRT, or NCT to perform a radiologic procedure until a hardship exemption is granted.
The hospital, FQHC, or a practitioner must reap ... ”
“... the Texas Administrative Code, Title 22, Part 9, Chapter 194, Subchapter A, Rule 194.7(c), adopted to be effective September 16, 2018, located here.
General medical radiologic technologists need to complete a minimum 24 hours of continuing education (CE) every 24 months (24 month timeli ... ”
“... Texas Administrative Code, Title 22, Part 9, Chapter 194, Subchapter A, Rule 194.7(c), adopted to be effective September 16, 2018, located here.
Limited medical radiologic technologists need to complete a minimum of 18 hours of continuing education (CE) every 24 months (24 month timeline ... ”
Description: TMB Bulletin Spring 2000
Document: ... tsbme.state.tx.us, click on the Board Rules, then Chapter 173, Physician Profiles). A Profile Update and Correction Form is being developed for physicians to revise and update their data. Physicians will have opportunities to correct or dispute information in their Profile before it is published. HB ...
Description: TMB Bulletin Spring 2005
Document: ... www.tsbme.state.tx.us and click on Board Rules. Chapter 162, Supervision of Medical Students. Amendments to 162.1 repealing requirement that supervising physician hold clinical faculty appointment and new 162.2 adding provisions of Chapter 186, Supervision of Physician Assistant Students. Chapte ...
Description: TMB Bulletin Spring 2006
Document: ... ation on rehabilitation orders is available under Chapter 180 of the Board Rules at www.tmb.state.tx.us/rules/rules/180.php
Anyone wishing to self-report an impairment in order to enter into a rehab order may do so by submitting the following information:
the approximate dates of intemperat ...
Description: TMB Bulletin Spring 2007
Document: ... nce the last issue of the Medical Board Bulletin: Chapter 163, Licensure , to amend 163.2, Definitions, to correct a reference; 163.5, Licensure Documentation to eliminate the requirement for all applicants to present certain documents to the Board, and 163.6, Examinations Accepted for Licensure reg ...
Description: TMB Bulletin Spring 2004
Document: ... anges that were published in the Texas Register : Chapter 162, Supervision of Medical School Students: Rule review, repeal of §§162.1-162.3, and new §162.1 regarding the requirements for Texas physicians who supervise medical school students in Texas. Chapter 163, Licensure: Amendments to §§163.1, 1 ...
Description: TMB Bulletin Spring 2002
Document: ... hanges that were published in the Texas Register: Chapter 161, General Provisions: rule review, repeal of 161.1-161.5, and new 161.1-161.13, regarding the purpose and function of the board, clarification of its organization and structure, and description of each committee s responsibilities. Chapter ...
Description: TMB Bulletin Spring 1997
Document: ... CONTENTS: Announcement Board Initiates CME Audits Chapter 194. Non-Certified Radiologic Technicians Errata Executive Director's Column Explanation of Annual Fees Illustrative Disciplinary Case Physician Laurels Position Statement: Unlicensed Practice of Medicine Prescriptive Authority A&A Texas Medi ...
Description: TMB Bulletin Spring 2008
Document: ... ww.tmb.state.tx.us/rules/rules/bdrules_toc.php . Chapter 161, General Provisions, amending 161.7 Executive Director, authorizes the Executive Director to delegate responsibilities and authority to other staff members. Chapter 162, Supervision of Medical Students, including changes in 162.1, relatin ...
Description: TMB Bulletin Spring 1999
Document: ... 5.03 of the Medical Practice Act and Board Rules, Chapter 191, there are four District Review Committees, each representing a geographic area of Texas. The members may serve the board in several ways, such as providing public information functions and reviewing investigative files. Their duties cons ...
Description: TMB Bulletin Spring 1998
Document: ... 733-2267, extension 158. Acupuncture Rule Changes Chapter 183, Acupuncture, repeal of current 183.17 and new sections 183.17 and 183.23, to implement Senate Bill 1765, 75th Legislature, which re quires the Board of Medical Examiners to certify acudetox specialists, annually renew certification, and ...
Description: TMB Bulletin May 2011
Document: ... summary of Board Rule Changes since January 2011. Chapter 163: Licensure, amendment to §163.13, relating to Expedited Licensure Process, deletes language that requires applicants for an expedited license to practice medicine to submit proof of eligibility for a visa immigration waiver. Chapter 164: ...
Description: TMB Bulletin Spring 2009
Document: ... d regulations.
The Texas Medical Board s rules, Chapter 169, Authority of Physicians to Supply Drugs, and Chapter 170, Pain Management, provide guidance and direction for physicians in prescribing dangerous drugs and controlled substances. The complete rules may be found at http://www.tmb.state.tx ...
Description: TMB Bulletin July 2012
Document: ... Treatment gram will allow physicians to view Act (Chapter 107 of the Texas a patient's opiate use without Occupations Code) and the rehaving to wait for records from a sulting Chapter 170 of the Texas previous provider. This database Medical Board rules. The rules has existed for some time, but is a ...
Description: TMB Bulletin March 2012
Document: ... tion. http:// www.tmb.state.tx.us/rules/rules.php CHAPTER 173. PHYSICIAN PROFILES. The Texas Medical Board adopted amendments to §173.1, concerning Profile Contents; and §173.3, concerning Physician-Initiated Updates. The amendment to §173.1 clarifies what utilization review services are subject to ...
Description: TMB Bulletin January 2012
Document: ... ard certification issued by a member board of the CHAPTER 163. LICENSURE: The amendment American Board of Medical Specialties or Bureau to §163.1, relating to Definitions, amends lanof Osteopathic Specialists, or by the American guage based on passage of House Bill 1380 Board of Oral and Maxillofaci ...
“... quirements is available under Board Rules Section Chapter 183, Section 183.4 Procedural Rules for Licensure Applicants. The following is paraphrased from that rule. We encourage you to read the entire rule. Submit an application online for licensure and pay the $305 applicat ... ”
What are the basic requirements to be licensed as an acupuncturist in Texas?
Information on licensure requirements is available under Board Rules Section Chapter 183, Section 183.4 Procedural Rules for Licensure Applicants. The following is paraphrased from that rule. We encourage you to read the entire rule.
“The authority to delegate is found in Chapter 157 of the Texas Occupations Code, and Title 22 of the Texas Administrative Code, Section 193. A physician is allowed to delegate certain duties to a qualified and properly trained person acting under the physician’s supervision:1) if in the opinio ... ”
What are the general rules related to AAs/CRNAs?
The authority to delegate is found in Chapter 157 of the Texas Occupations Code, and Title 22 of the Texas Administrative Code, Section 193. A physician is allowed to delegate certain duties to a qualified and properly trained person acting under the physician’s supervision:
1) if in the opinion of the delegating physician the act can be properly and safely performed by the person to whom the medical act is delegated;
2) the act is performed in its customary manner; and
3) the performance of the act by the delegate is not in violation of any other statute.
It is clear that AAs can be delegated certain tasks under Chapter 157. The question is the extent allowable of such delegation. The key provision that needs to be examined is likely “not in violation of any other statute.”
Although the Nursing Act describes what a CRNA can do in regard to anesthesia, there is overlap of regulation of CRNAs between the Medical Board and Nursing Board. CRNAs are subject to physician delegation under the Medical Practice Act. The delegating physician can limit what a CRNA is allowed to provide under a Prescriptive Authority Agreement (PAA) or Standing Order, despite what may be allowed under Nursing Board rules and regulations.
The level of supervision required for any AA (or any delegated provider) is determined based on training, knowledge, and experience, as determined by the physician. For CRNAs, whether any level of physician supervision is required will depend upon those same factors, in addition to applicable federal and state statutes, regulations, bylaws, and ethical standards, if any. However, AAs and CRNAs cannot practice independently and require physician delegation. A hospital or facility can set their own standards, policies, etc., related to delegation and supervision as long as it does not violate Chapter 157, board rules, or other applicable federal and state statutes and regulations. Although AAs most commonly work under an anesthesiologist physician, any physician may supervise and delegate to AAs; however, the standard of care must be met and the delegating physician remains responsible for the AA’s actions.
One difference between an AA and CRNA is the ability to order and prescribe dangerous and controlled substances to patients for anesthesia and anesthesia-related services. Under section 157.058, a CRNA pursuant to the physician’s order and in accordance with facility policies or bylaws may select, obtain, and administer those drugs appropriate to accomplish the order. The physician’s order for anesthesia or anesthesia-related services is not required to specify a drug, dose, or administration technique.
As previously stated, the Nursing Act describes what a CRNA can do in regard to anesthesia. However, the delegating physician or facility can limit what a CRNA is allowed to provide under a PAA or Standing Order, despite what may be allowed under Nursing Board rules and regulations.
While AAs are not allowed to select drugs, determine dose, or administration technique for anesthesia or anesthesia-related services without specification by the supervising physician through an order, they perform many of the other same key duties performed by CRNAs. These duties include conducting preoperative physical exams, administering medications, evaluating and responding to life-threatening situations, setting up external and internal monitors, and implementing general and site-specific anesthetic techniques.
Another area of concern relates to handing-off patient care from CRNAs to AAs. RNs have the authority to delegate certain nursing tasks to unlicensed individuals; however, a CRNA and AA do not have any specific delegation authority concerning anesthesia tasks. A physician has the authority to delegate the process of anesthesia-related patient care, including the transfer or hand-off of care from a CRNA to an AA through an order (standing or patient-specific) or protocol. A CRNA or AA cannot set-up or independently delegate a hand-off or step-down process.
While the Nursing Act places responsibility for patient hand-off on a CRNA, if the physician orders a hand-off process from CRNA to AA, and this is memorialized in orders, protocols, etc., then the CRNA does not have the authority to determine the AA is not competent. The reason is that the physician has already made the determination of competency under Chapter 157.001.
Because the CRNA’s authority also arises through the delegating physician, and is not independent of that physician, a CRNA cannot override a physician Order related to this hand-off scenario. If this hand-off became an issue, the CRNA would have a defense (absolute) because the physician has already determined the competency of the AA to accept this patient.
“... erification database. The Texas Occupations Code, Chapter 154.006 requires that information be made available through the physician profile system. In addition to the statutorily required information, the TMB has adopted rules (Chapter 173) regarding the contents of the physician profile system. Due ... ”
What information is available on a physician’s Profile?
Statutory regulations require the TMB to maintain a profile on each licensed physician. This profile information is gathered in conjunction with the license registration and is available to the public through our online verification database. The Texas Occupations Code, Chapter 154.006 requires that information be made available through the physician profile system. In addition to the statutorily required information, the TMB has adopted rules (Chapter 173) regarding the contents of the physician profile system. Due to concern expressed by licensees regarding identity theft and the public disclosure of exact dates of birth, the TMB no longer includes exact dates of birth in our data products, online verification databases or verbal verifications. We do however continue to include birth year.
“... health organization certified by the board under Chapter 177 of this title (relating to Certification of Non-Profit Health Organizations); a clinic owned or operated by a physician who treats patients within the physician's area of specialty who personally uses other forms of treatment, including s ... ”
Who does not need to register a pain management clinic?
Regulations regarding the registration and operation of pain management clinics do not apply to the following settings:
Note: The TMB cannot give legal advice. Please consult an attorney if you have questions regarding whether or not your clinic meets one of the exemptions listed above. However, the Board does have inspection authority, and owners of clinics that have not been properly registered can be investigated.
“... et.seq. and the Texas Controlled Substances Act, Chapter 481 of the Texas Health and Safety Code, relating to the prescribing and dispensing of controlled substances. The medical director of a pain management clinic must, on an annual basis, ensure that all personnel: • are properly licensed, ... ”
Who can own or operate a pain management clinic?
A pain management clinic may not operate in Texas unless the clinic is owned and operated by a medical director who: • is a physician who practices in Texas • has an unrestricted medical license • holds a certificate of registration for that pain management clinic In addition, the owner/operator of a pain management clinic, an employee of the clinic, or a person with whom a clinic contracts for services may not: • have been denied, by any jurisdiction, a license issued by the Drug Enforcement Agency or a state public safety agency under which the person may prescribe, dispense, administer, supply, or sell a controlled substance; • have held a license issued by the Drug Enforcement Agency or a state public safety agency in any jurisdiction, under which the person may prescribe, dispense, administer, supply, or sell a controlled substance, that has been restricted; or • have been subject to disciplinary action by any licensing entity for conduct that was a result of inappropriately prescribing, dispensing, administering, supplying, or selling a controlled substance A pain management clinic may not be owned wholly or partly by a person who has been convicted of, pled nolo contendere to, or received deferred adjudication for: • an offense that constitutes a felony; or • an offense that constitutes a misdemeanor, the facts of which relate to the distribution of illegal prescription drugs or a controlled substance as defined by Texas Occupations Code Annotated §551.003(11) The medical director of a pain management clinic must operate the clinic in compliance with Drug Prevention and Control Act, 21 U.S.C.A. 801 et.seq. and the Texas Controlled Substances Act, Chapter 481 of the Texas Health and Safety Code, relating to the prescribing and dispensing of controlled substances. The medical director of a pain management clinic must, on an annual basis, ensure that all personnel: • are properly licensed, if applicable, • are trained including 10 hours of continuing medical education related to pain management, and • are qualified for employment.
“... ules I through V or Penalty Groups 1 through 4 of Chapter 481, Health and Safety Code (Texas Controlled Substances Act). The term includes a device or drug that bears, or is required to bear, the legend: “Caution: federal law prohibits dispensing without prescription” or “Rx only&r ... ”
What is a dangerous drug? Are these legend drugs?
Texas is one of just a few states that use the term “dangerous drugs.” The Dangerous Drug Act defines a dangerous drug as a device or drug that is unsafe for self-medication and that is not included in Schedules I through V or Penalty Groups 1 through 4 of Chapter 481, Health and Safety Code (Texas Controlled Substances Act). The term includes a device or drug that bears, or is required to bear, the legend: “Caution: federal law prohibits dispensing without prescription” or “Rx only” or another legend that complies with federal law. Many other states use the term “legend drugs.”
“... physician who issues a standing delegation under chapter 203 generally “is not liable in connection with an act performed under that standing delegation order”). Thus, we cannot conclude that the liability of a physician delegating the administration of anesthesia to a CRNA is limited s ... ”
Are physicians potentially subject to discipline for violations of the standard of care by CRNAs to whom they have delegated the selection or administration of anesthesia or the care of an anesthetized patient?
Yes, potentially. Although physicians are not required to supervise CRNA’s for delegated tasks, they nonetheless remain subject to potential liability for violations of the standard of care by CRNAs, depending on federal and state statutes and regulations. The degree to which a physician is required to supervise a CRNA during the performance of a task in anesthesia services is left to the “physician’s professional judgment in light of other relevant federal and state laws, facility policies, medical staff bylaws, and ethical standards.” (Texas Attorney General Opinion No. JC-0117). However, physician supervision during the medical management of a patient while undergoing an anesthetic may require supervision dependent on federal and state statutes and regulations.
Additionally, Texas Attorney General Opinion No. KP-0353 found “In authorizing physicians to delegate the administration of anesthesia to CRNAs, the Legislature did not expressly limit the liability of the delegating physician. See TEX. OCC. CODE § 157.058; cf. id. § 157.004(c) (providing that in specified circumstances a physician who issues a standing delegation under chapter 203 generally “is not liable in connection with an act performed under that standing delegation order”). Thus, we cannot conclude that the liability of a physician delegating the administration of anesthesia to a CRNA is limited solely to the determination of competency. Questions of physician liability in any specific context are highly factual and not an appropriate determination for the opinion process. See Tex. Att’y Gen. Op. No. GA-0446 (2006) at 18 (“Questions of fact are not appropriate to the opinion process.”) (Page 4 with emphasis added.)
“... KP-0353 also found “…the language of chapter 157 is not the only relevant authority to consider in addressing the question of physician supervision over acts delegated to a CRNA. Federal regulations limiting Medicare coverage and conditioning hospital participation in Medicare and ... ”
When is Physician supervision of a CRNA required?
Regardless of the circumstances when supervision is or is not required, it is important to remember that the delegating physician must abide by all required federal and state statutes and regulations regarding delegation. The physician retains responsibility of the medical management of the patient. Therefore, the delegating physician must consider the delegatee’s education, training, and experience prior to delegating. Additionally, delegation may be revoked by the delegating physician at any time.
The Texas Attorney General has issued three opinions on CRNA supervision. The latest opinion found that although physician supervision of a CRNA is not required in Texas Occupations Code Sec. 157.058, other federal and state statutes and regulations may require physician supervision of a CRNA, a CRNA may not administer an anesthetic that is a controlled substance outside the presence of a physician, and the Legislature did not expressly limit the liability of the delegating physician.
Specifically, Texas Attorney General Opinion KP-0353 found “Section 157.058 of the Occupations Code does not, by itself, require a physician who properly delegates anesthesia-related tasks to a certified registered nurse anesthetist (“CRNA”) to supervise the performance of those acts.” (Page 5)
However, KP-0353 also found “…the language of chapter 157 is not the only relevant authority to consider in addressing the question of physician supervision over acts delegated to a CRNA. Federal regulations limiting Medicare coverage and conditioning hospital participation in Medicare and Medicaid programs require physician supervision of a CRNA when administering anesthesia in certain circumstances. See, e.g., 42 C.F.R. §§ 416.42(b)(2), 482.52(a)(4), 485.639(c)(1)(v), (2) (requiring a CRNA to operate under a physician’s supervision when administering anesthesia in certain circumstances). Furthermore, a CRNA may not administer an anesthetic that is a controlled substance outside the presence of a physician. See TEX. HEALTH & SAFETY CODE §§ 481.002(1)(A) (defining “administer” to require agent to apply controlled substance in presence of physician), .071(a) (prohibiting physician from causing controlled substance to be administered under physician’s “direction and supervision” except for valid medical purpose and in course of medical practice). And a CRNA may not obtain an anesthetic that is a dangerous drug unless a physician has listed that CRNA as the physician’s designated agent. See id. §§ 483.001(4) (defining “designated agent”), .022(a) (requiring physician to name each designated agent in writing). (Page 3 with emphasis added.)
Finally, KP-0353 found “Whether and the extent to which physician supervision is required for an act delegated to a CRNA will depend on the specific act delegated, the type of facility in which the CRNA performs the act, and any relevant regulations of that facility. And while section 157.058 authorizes a physician to delegate to a CRNA, a physician is never required to do so. If a physician is concerned about a CRNA’s ability to perform a delegated act or desires to limit the delegation, the physician retains the authority to refrain from delegating, to limit the delegation, or to supervise the delegation to whatever extent the physician determines necessary. In sum, the authority to delegate provided by section 157.058 of the Occupations Code does not eliminate the need to comply with all other applicable statutes, regulations, bylaws, ethical standards, and a physician’s own professional judgment. See TEX. OCC. CODE § 157.007 (“An act delegated by a physician under [chapter 157] must comply with other applicable laws.”). (Page 4 with emphasis added.)
“... urse approved by the board. In all settings under Chapter 192, at a minimum, at least two persons, including the surgeon or anesthesiologist, shall maintain current competency in basic life support. ”
What are the standards for anesthesia services relating to OBA?
Physicians and anesthesiologists shall maintain current competency in ACLS, PALS, or a course approved by the board. In all settings under Chapter 192, at a minimum, at least two persons, including the surgeon or anesthesiologist, shall maintain current competency in basic life support.
“... ces, must still meet all other requirements under Chapter 192. ”
Who does not need to register for office-based anesthesia?
OBA registration does not apply to physicians who practice in the following settings:
Note: physicians that provide only level I services, must still meet all other requirements under Chapter 192.