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“... ian Assistant Supervision
Advanced Practice Nurse Delegation
”
“What is this? A request for evaluation of your criminal history and potential eligibility for licensure prior to application for licensure as a physician, physician assistant, acupuncturist, medical radiologic technologist, non-certified radiological technician, respiratory care practitio ... ”
“... al processing fee will not be required.
To request a hard copy registration form, please contact the Registration Department at registrations@tmb.state.tx.us or (512) 305-7030.
”
“... -800-201-9353 and follow the automated prompts to request a complaint form.
Some patients' complaints do not fall within the Board's jurisdiction and should be directed to the local medical or osteopathic society. Complaints against other health care providers (nurses, dentists, pharmacists) or hosp ... ”
“... g. primary practice address, hospital privileges, delegation information, etc.) All verifications also include a description of any action taken by the Board against a licensee.
Data is updated daily and may be considered the most current information available. Access to this computer system is auth ... ”
“... ourse shall be required to be made available upon request by Board Staff, including, but not limited to, during an on-site audit of the clinic, or during the certificate renewal process. The Board does have the authority to conduct audits and inspections at clinics to ensure compliance with al ... ”
“... being started and opportunity to renegotiate the request if charges are too high;
choose whether to inspect the requested information at a time mutually acceptable to the agency and the requestor; receive copies of the information; or both;
receive a waiver or reduction of charges if our agency det ... ”
“... ation Act (PIA). Consequently, when making a request to TMB under the PIA, please note that these documents/materials are excepted from release to the public by two Pre-Determination letters from the Office of the Attorney General, available at the links below:
OAG Predetermination Lett ... ”
“... in writing to pay the costs before finalizing the request;
inform requestors if the information cannot be provided promptly and establish a date and time to provide it within a reasonable time;
contact requestors who wish to review records to set up a mutually agreeable time for doing so;
ask for a ... ”
“Procedures to Request and Obtain Information
Submit a written request (mail, fax, e-mail or in person) according to the agency's procedures. Please click on the last tab for information on how to request open records.
Include enough description and detail about the information requeste ... ”
“... ges within 10 days of the date we send it, or the request may be deemed withdrawn.
If estimated costs exceed $100, our agency may require a bond, prepayment or deposit.
Requestors may ask us to determine whether providing the information primarily benefits the general public, which may result in a w ... ”
“How to Request Information from this Agency
Address your written request to:
Open Records
Texas Medical Board
You may send your request by:
mail to: P.O. Box 2018, Austin TX 78768
e-mail to: openre ... ”
“... sent to the agency, is subject to disclosure upon request pursuant to the Texas Public Information Act, codified at Texas Government Code, Section 552.011 (Vernon's 2000). However, public provided e-mail addresses that are used to communicate directly with the agency are exempt from open records and ... ”
“... egislature through the Legislative Appropriations Request. The development and implementation of an agency Employee Awareness Plan will not require a significant amount of funding.
(5) A Utility Awareness Plan through which the agency or institution will educate its personnel on utility conser ... ”
“... s for licensure in effect at that time.
To request cancellation of a license, complete and return the cancellation request form (link below) to the Board for approval before the expiration date of the current registration permit. Refunds of registration fees already paid cannot be made. ... ”
Description: TMB Bulletin January 2012
Document: ... duct. Impairment, inadequate supervision/improper delegation, improper practice closure, failure to cooperate with Board.
M2673
8/10/11
L4029
8/15/11
G4161
6/21/11
K1753
9/15/11
M0156
10/31/11
H7724
8/23/11
G3585
10/17/11
G8286
11/30/11
Mitchell, Roderick, M.D. Moran, Cynthia H., M. ...
Description: TMB Bulletin December 2012
Document: ... cupuncture Examiners
December 2012
Prescriptive Delegation Waiver Requests
The board has authority to waive or modify any of the site or supervision requirements for a physician delegating prescriptive authority to advanced practice nurses or physician assistants. But the board's rules state that ...
Description: Rule Changes December 23, 1997
Document: ... ysician assistants. Chapter 193.1-193.7, Standing Delegation Orders reorganization of the entire chapter, incorporates several legislative changes, deletes old section 7 regarding rad techs and renumbers the sections. Chapter 194.1-194.11, Non-Certified Radiologic Technicians new sections outlining ...
Description: Rule Changes November 30, 2009
Document: ... , with proposed amendment to §179.4, relating to Request for Information and Records from Physicians, sets out the procedure for requiring that, based on probable cause, an applicant or licensee submit to a physical or mental examination based on an order of the Board issued by the Executive Direct ...
Description: Rule Changes November 30, 2003
Document: ... 04 of the 78th Legislature. Chapter 193, Standing Delegation Orders. New §193.11 regarding delegation and supervision of the use of lasers. Chapter 196, Voluntary Surrender of a Medical License. Amendments to §§196.1-196.3 for general cleanup of the chapter. NOTE: Chapter 168, Persons with Criminal ...
Description: Rule Changes November14, 2000
Document: ... ng site-based registration. Chapter 193, Standing Delegation Orders - rule review and proposed amendments regarding cites to Texas Occupations Code Annotated. Chapter 194, Non-Certified Radiologic Technicians - rule review and proposed amendments regarding current registry with the Texas Department ...
Description: Rule Changes October 17, 2010
Document: ... The repeal and replacement of §174.6, concerning Delegation to and Supervision of Telepresenters, repeals §174.6 and adds new language for new §174.6, concerning Telemedicine Medical Services Provided at an Established Medical Site. The Board has determined that the new language is necessary to est ...
Description: Rule Changes October 03, 2010
Document: ... XAMINING%20BOA RDS.html#306 Chapter 193, Standing Delegation Orders: Amendments to §193.6 clarify that physicians who delegate to certified registered nurse anesthetists (CRNAs) who only sign or carry out prescription drug orders are not required to register with the Board. The Board has determined ...
Description: Rule Changes September 28, 2006
Document: ... gation for substance abuse. Chapter 193, Standing Delegation Orders, 193.12 relating to the immunization of persons over 65 by physicians' offices.
Description: Rule Changes September 27, 2007
Document: ... rescription; and 181.6 Physician s Prescriptions: Delegation, relating to establishing that the verification of a contact lens prescription may substitute for an original signature to create a valid contact lens prescription. Chapter 191, District Review Committees, amending 191.4 Activities and Sco ...
Description: Rule Changes September 24, 1998
Document: ... her to follow this advice." Chapter 193, Standing Delegation Orders, new section 193.8, regarding pharmacist immunizations under protocol.
Description: Rule Changes September 21, 2000
Document: ... 33 regarding oral argument. Chapter 193, Standing Delegation Orders - new §193.10, regarding collaborative management of glaucoma.
Description: Rule Changes September 14, 2003
Document: ... uing acupuncture education. Chapter 193, Standing Delegation Orders: Amendments to §§193.2 and 193.6 regarding the delegation of prescriptive authority as mandated by House Bill 1095 of the 78th Legislature.
Description: Rule Changes September 12, 2004
Document: ... es and registration. Chapter 193, Standing Orders Delegation. Amendments to §193.11, Use of Lasers, regarding continuing education on the use of laser devices.
Description: Rule Changes August 10, 2008
Document: ... pter 196 of the Board Rules. Chapter 193 Standing Delegation Orders, with amendments to §193.1, Purpose, updates name of Texas Medical Board; §193.2, Definitions, updates name of Texas Physician Assistant Board; §193.4, Scope of Standing Delegation Orders, clean-up language; §193.6, Delegation of th ...
“... an APRN or PA provided all requirements for such delegation are met. ”
How many delegating physicians may one APRN or PA have?
There is no limit to the number of physicians who may delegate prescriptive authority to an APRN or PA provided all requirements for such delegation are met.
“... ribe this equipment provided all requirements for delegation of prescriptive authority are met. ”
Is prescriptive authority required to order durable medical equipment (DME)?
Yes. SB 406 clarified that it is necessary to have prescriptive authority to order these devices. In the past, it was not clear to DME suppliers that APRNs and PAs had this authority. The changes to the law as a result of the passage of SB 406 clearly indicate that APRNs and PAs may order or prescribe this equipment provided all requirements for delegation of prescriptive authority are met.
“... frame, each licensing board has the authority to request this information. Failure to provide the requested information could result in disciplinary action against the professional license. ”
Do I have to produce my prescriptive authority agreement or facility-based protocol if a licensing board asks to see it?
Yes. You are required to provide a copy of the prescriptive authority agreement to the board that requested it within three business days. Although SB 406 did not specifically note that facility-based protocols must also be submitted within this time frame, each licensing board has the authority to request this information. Failure to provide the requested information could result in disciplinary action against the professional license.
“All prescriptive delegation requires adequate supervision under the Medical Practice Act. As such, a physician delegating to an APRN or PA must adequately supervise those individuals. An individual physician may serve in both the supervising and delegating role and does not need to be ph ... ”
What are the Texas Medical Board’s requirements for a physician who delegates to an APRN or PA?
All prescriptive delegation requires adequate supervision under the Medical Practice Act. As such, a physician delegating to an APRN or PA must adequately supervise those individuals. An individual physician may serve in both the supervising and delegating role and does not need to be physically present at all times to be considered to have adequate supervision.
“... dical aspects of patient care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than requiring multiple documents, delegation protocols can now be included in one document the prescriptive authority agreement. The prescriptive authority agreement n ... ”
Do I need to have a protocol in addition to a prescriptive authority agreement?
APRNs and PAs are required to have delegated authority from a licensed physician in order to provide medical aspects of patient care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than requiring multiple documents, delegation protocols can now be included in one document the prescriptive authority agreement. The prescriptive authority agreement need not describe the exact steps that an advanced practice registered nurse or physician assistant must take with respect to each specific condition, disease, or symptom, however.
“The prescriptive authority agreement designates who may serve as an alternate physician if alternate physician supervision will be utilized. If an alternate physician(s) will participate in the quality assurance and improvement meetings with the APRN or PA, this information must be included in ... ”
What if an alternate physician is involved in delegation of prescriptive authority on a temporary basis?
The prescriptive authority agreement designates who may serve as an alternate physician if alternate physician supervision will be utilized. If an alternate physician(s) will participate in the quality assurance and improvement meetings with the APRN or PA, this information must be included in the prescriptive authority agreement.
“... xercise prescriptive authority under one of these delegation mechanisms. ”
Is a prescriptive authority agreement required in a hospital or long term care facility-based practice?
Although it is possible to use a prescriptive authority agreement in a hospital or long term care facility based practice, it is not required. You may continue to practice under protocols in these settings. APRNs and PAs must exercise prescriptive authority under one of these delegation mechanisms.
“... artment chair, or a physician who consents to the request of the medical director or chief of the medical staff to delegate. ”
Who may delegate prescriptive authority in a hospital facility-based practice?
In a hospital facility based practice, the delegating physician may be the medical director, the chief of medical staff, the chair of the credentialing committee, a department chair, or a physician who consents to the request of the medical director or chief of the medical staff to delegate.
“In a long term care facility based practice, delegation is by the medical director. ”
Who may delegate prescriptive authority in a long term care facility based practice?
In a long term care facility based practice, delegation is by the medical director.
“... d 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 ... ”
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.)
“... eral 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 ... ”
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.)
“APRNs or PAs may prescribe schedule II drugs in the following situations: (1) in a hospital facility-based practice, in accordance with policies approved by the hospital's medical staff or a committee of the hospital's medical staff as provided by the hospital's bylaws to ensure patient safety ... ”
Who can prescribe Schedule II drugs under physician delegation?
APRNs or PAs may prescribe schedule II drugs in the following situations:
(1) in a hospital facility-based practice, in accordance with policies approved by the hospital's medical staff or a committee of the hospital's medical staff as provided by the hospital's bylaws to ensure patient safety and as part of care provided to a patient who:
(A) has been admitted to the hospital for an intended length of stay of 24 hours or greater; or
(B) is receiving services in the emergency department of the hospital; or
(2) as part of the plan of care for the treatment of a person who has executed a written certification of a terminal illness, has elected to receive hospice care, and is receiving hospice treatment from a qualified hospice provider.
“... pital anddoes not qualify as an eligible site for delegation of schedule II authority. The physician may only delegate authority to prescribe controlled substances in schedules III through V in this setting. Authority to prescribe dangerous drugs, nonprescription drugs and devices may be ... ”
Can schedule II authority be delegated in a free standing emergency department that is affiliated with a hospital?
No. A free standing emergency department is not located within the hospital anddoes not qualify as an eligible site for delegation of schedule II authority. The physician may only delegate authority to prescribe controlled substances in schedules III through V in this setting. Authority to prescribe dangerous drugs, nonprescription drugs and devices may be delegated in any setting.
“Yes. Nothing changed for delegation of prescriptive authority for controlled substances in schedules III through V. ”
Can APRNs and PAs in hospital-based clinics continue to prescribe drugs in schedules III through V?
Yes. Nothing changed for delegation of prescriptive authority for controlled substances in schedules III through V.
“Upon written request TMB will provide a state board verification to another state board regarding licensees. The verification includes: licensee's name, license or permit number, issue date, expiration date, disciplinary status, and our board seal will be affixed.There is no fee for state board veri ... ”
How do I get a verification of my Texas license sent to another state?
Upon written request TMB will provide a state board verification to another state board regarding licensees. The verification includes: licensee's name, license or permit number, issue date, expiration date, disciplinary status, and our board seal will be affixed.
There is no fee for state board verifications. Please allow 10 working days to process your verification. The verification will be mailed directly to the state board of your request.
The form is avaliable under Verification Request in the "Licensee Resources" section of our website.