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“Physicians are required to register with the TMB if the physician delegates prescriptive authority to Advanced Practice Registered Nurses (APRNs). Current registered delegations to APRNs are displayed in this section of the physician profile. ”
“... 104 (2003) fee per registration, the $13.48 Prescription Monitoring Program (PMP) fee, and a $5 Office of Patient Protection fee for the first year, with an additional $1 charged for any subsequent year. These fees are required by statute and cannot be pro-rated. The remaining amount is requir ... ”
“... nd if prescribing drugs, must have a prescriptive delegation agreement with their supervising physician(s).
The Licensure Department of the Texas Physician Assistant Board is committed to furthering the mission of the Board by ensuring quality healthcare for the citizens of Texas by upholding ... ”
“... sp;PDF | Word
Chapter 170 -
Prescription of Opioid Antagonists: HTML | PDF | Word
Chapter 171 -
Interstate Medical Licensure Compact: HTML | PDF | Word
Physician Assistants
Chapt ... ”
“... signing for the receipt of pharmaceutical sample prescription medications and distributing the samples to patients in a specific practice setting where the physician assistant is authorized to prescribe pharmaceutical medications or order a drug or device, as provided by the Medical Practice Act, C ... ”
“... iration date.
Supervision and Prescriptive delegation:
To register Supervision and/or Delegation, use the online system to file the notice of intent to practice/supervise forms required of PAs and physicians AND to register prescriptive authority, prior to beginning to practice.
... ”
“...
The initial registration fee includes the $13.48 Prescription Monitoring Program (PMP) fee, and a $5 Office of Patient Protection fee for the first year, with an additional $1 charged for any subsequent year. These fees are required by statute and cannot be pro-rated. The remaining amount is requir ... ”
“... he biennial registration fee includes the $13.48 Prescription Monitoring Program (PMP) fee, $5.25 for the Physician Health Program (PHP) and a $2 Office of Patient Protection fee. These fees are required by statute. The remaining $535 is the fee required by the TMB.
These fees are explained ... ”
“... o can prescribe Schedule II drugs under physician delegation?
Can schedule II authority be delegated in a free standing emergency department that is affiliated with a hospital?
How often is physician consultation required when prescribing controlled substances?
Can APRNs and PAs in hospital-ba ... ”
“Online Supervision and Prescriptive Delegation Registration System - Click to access system.
Use the online system to register prescriptive authority AND to file the notice of intent to practice/supervise as required of PAs and physicians. Hard copy supervision and delegation forms are no lon ... ”
“... ature of the prescribing practitioner, unless the prescription is called into the pharmacy
”
“... des an $80 Senate Bill 104 (2003) fee, the $13.48 Prescription Monitoring Program (PMP) fee, $11.00 for the National Practitioner Data Bank (NPDB), $5.25 for the Physician Health Program (PHP), and a $2 Office of Patient Protection fee. These fees are required by statute. The remaining $37 ... ”
“... &D premiums.
Other insurance benefits include prescription drug coverage, dental coverage for employee and eligible dependents, disability coverage for employee only, term life and accidental death and dismemberment for employee and eligible dependents, and TexFlex Health Care and Day Care Accou ... ”
“... ww.immunizetexas.com.
Medicaid Prescribers Prescription Pad Notice
As of April 1, 2008, practitioners who prescribe to Medicaid patients will be required to use tamper-resistant prescription paper when writing a prescription for any drug for Medicaid recipients.
Tamper Resistant Rx Provider N ... ”
“... ority of patients are issued on a monthly basis a prescription for opioids, benzodiazepines, barbiturates, or carisoprodol, but not including suboxone.
Please visit Chapter 195 of the Board rules for the complete regulations.
Board Rules
... ”
Description: TMB Bulletin Spring 2006
Document: ... dministrative violations.
Chapter 193, Standing Delegation Orders 193.2 Definitions and 193.6 Delegation of the Carrying Out or Signing of Prescription Drug Orders to Physician Assistants and Advanced Practice Nurses, to include elimination of registration of prescriptive delegation with the board ...
Description: TMB Bulletin Spring 2007
Document: ... from administering, prescribing or delegating the prescription of intravenous Lidocaine or intravenous Colchicine or their generic counterparts; requiring that he complete additional continuing medical education in the areas of pain management and endocrinology; and assessing an administrative penal ...
Description: TMB Bulletin Spring 2004
Document: ... stent with Senate Bill 104. 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 and applications for waiver and meetings of the Prescriptive Delegation Waiver Advisory Com ...
Description: TMB Bulletin Spring 2010
Document: ... ed protocols for Dr. Henderson’s
supervision and delegation of prescriptive authority
to physician extenders. Dr. Henderson must submit to
the Board the names of up to three potential consul-
tants within 30 days. Once approved by the Board,
the consultant must provide a list of recommended
rev ...
Description: TMB Bulletin Spring 2002
Document: ... ection Formal Complaints New Controlled Substance Prescription Forms Available Continuing Medical Education Reminder Disciplinary Actions Governor Appoints New Board Member Governor Rick Perry announced the appointment of three new members of the Texas State Board of Medical Examiners. They attended ...
Description: TMB Bulletin Spring 1997
Document: ... icle written by Jennifer Seltzer, Pharm D., "Oral Prescription Medications and Black Box Warnings." The article was mistakenly attributed to Curtis Burch. The Medical Board Report would like to extend its apologies to Jennifer Selzer and thank her for her contributions to this newsletter.
Executive ...
Description: TMB Bulletin Spring 1999
Document: ... for inst itutional permits. Chapter 193, Standing Delegation Orders, amendment to section 193.2 relating to definitions. Chapter 197, Emergency Medical Service, repeal of sections 197.2-197.5 and new sections 197.2-197.5, that will update rules to current practices. For copies of these rules, write ...
Description: TMB Bulletin Spring 1998
Document: ... rvision of a qualified anesthesiologist under the delegation provisions of the Medical Practice Act, Section 3.06(d)(1). The responsibility for maintaining these standards is that of the supervising anesthesiologist who, ultimately, remains responsible for all delegated functions. For a copy of the ...
Description: TMB Bulletin January 2011
Document: ... ate
Houston is the "dark heart" of Texas' growing prescription drug abuse problem, according to the Houston Chronicle, accounting for a quarter of complaints about doctors' suspect prescriptions and one-sixth of the state's 1,900 annual accidental fatal overdoses. Typically, these are walk-in, cash- ...
Description: TMB Bulletin May 2011
Document: ... oby's son, who had a known history of illicit and prescription drug abuse, died due to multiple drug toxicity. Police investigating the son's death discovered multiple empty prescription pill bottles under the son's bed. The majority were labeled as having been prescribed by Dr. Jacoby to his son's ...
Description: TMB Bulletin Spring 2009
Document: ... ubstance arrests are based on recreational use of prescription medications, according to the Jefferson County sheriff s office. The National Association of Drug Diversion Investigators identifies 57 prescription drugs that are commonly diverted. Some of the most frequently diverted/abused pharmaceut ...
Description: TMB Bulletin July 2012
Document: ... The United States is experiencing an epidemic of prescription opioid misuse and related deaths, mostly unintentional. The State of Texas has experienced this epidemic mostly through the prescribing of the "Unholy Trinity" of hydrocodone, lorazepam, and carisoprodol, but methadone, oxycodone, and fe ...
Description: TMB Bulletin March 2012
Document: ... study is 90 percent of more than 100 drugs, both prescription and over-the-counter, were good to use even 15 years after the expiration date. The U.S. Food and Drug Administration maintains an extensive website devoted to the issue. For more information, visit http://www.fda.gov/Drugs/DrugSafety/Dr ...
Description: TMB Bulletin January 2012
Document: ... ts. Inadequate medical records for five patients, prescription of dangerous drugs or controlled substances to one with whom there is a close personal relationship in absence of immediate need. Failure to meet the standard of care, failure to safeguard against potential complications, nontherapeutic ...
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 ...
“... 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.” ”
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.”
“... 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.
“... nd §481.002, Health and Safety Code. A prescription is an order to dispense a drug or device to a patient for self-administration as defined by §551.003, Occupations Code. ”
What is the difference between medication orders and prescriptions?
A medication order is an order for administration of a drug or device to a patient in a hospital for administration while the patient is in the hospital or for emergency use on the patient’s release from the hospital, as defined by §551.003, Occupations Code and §481.002, Health and Safety Code. A prescription is an order to dispense a drug or device to a patient for self-administration as defined by §551.003, Occupations Code.
“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.
“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.
“... lt with the delegating physician for refills of a prescription for controlled substances after the initial 90 day supply. Consultation is also required when prescribing controlled substances for children under the age of two years. In both cases, the consultation must be documented in th ... ”
How often is physician consultation required when prescribing controlled substances?
APRNs and PAs must consult with the delegating physician for refills of a prescription for controlled substances after the initial 90 day supply. Consultation is also required when prescribing controlled substances for children under the age of two years. In both cases, the consultation must be documented in the patient’s medical record.
“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.
“... ian who may be subject to discipline for improper delegation dependent upon the facts and circumstances of each case, and how state statutes and regulations apply in those situations. ”
Is a CRNA under a valid delegation order, subject to discipline by the Texas Medical Board under the Medical Practice Act for a violation of the standard of care in the selection and administration of anesthesia or the care of an anesthetized patient?
No, while the selection and administration of anesthesia is a medical act, if such an act was validly delegated to a CNRA by a physician, the act is considered to be within the practice of nursing and governed by the Nursing Practice Act. Any discipline for a violation of the standard of care by a CRNA would be carried out by the Texas Board of Nursing under the authority of the Nursing Practice Act. Ultimate responsibility and accountability for the medical management of a patient under anesthesia remains with the delegating physician who may be subject to discipline for improper delegation dependent upon the facts and circumstances of each case, and how state statutes and regulations apply in those situations.