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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, $15.00 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), $15.00 for the Physician Health Program (PHP), and a $2 Office of Patient Protection fee. These fees are required by statute. The remaining $3 ... ”
“... &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 172 of the Board rules for the complete regulations.
Board Rules
... ”
Description: Rule Changes June 29, 2006
Document: ... nclude amendments to 174.2, Definitions and 174.6 Delegation to and Supervision of Telepresenters regarding delegation of tasks and activities by a physician to a telepresenter. Chapter 178, Complaints , to include amendments to 178.8, Appeals regarding the deletion of the deadline for filing an app ...
Description: Rule Changes June 24, 2009
Document: ... sional relationship has been established, for the prescription of drugs for a partner of a patient who may have a sexually transmitted disease. The Board has determined that the amendment to the rule addresses a serious public health issue and is intended to allow physicians to treat persons with se ...
Description: Rule Changes May 09, 1999
Document: ... f intent to practice forms. Chapter 193, Standing Delegation Orders, sections 193.2, relating to the definition of the word "submit."
Description: Rule Changes May 09, 2002
Document: ... ce. Effec tive May 9, 2002. Chapter 193, Standing Delegation Orders. Amendment to section 193.6 regarding the delegation of prescriptive authority to alternate practice sites as specified in SB1166. Effective May 9, 2002.
Description: Rule Changes March 04, 1998
Document: ... a patient may request and receive a contact lens prescription and under which a physician shall provide such prescription, as mandated by the 75th Legislature through the Texas Contact Lens Prescription Act Chapter 183, Acupuncture, repeal of current 183.17 and new sections 183.17 and 183.23, to im ...
Description: Rule Changes March 08, 2001
Document: ... fficient reports, and fees. Chapter 193, Standing Delegation Orders - proposed amendment to 193.6(h) to correct a cite to the Texas Occupations Code Annotated.
Description: Rule Changes March 06, 2003
Document: ... al clean-up of the chapter. Chapter 193, Standing Delegation Orders. Amendments to '193.6 regarding supervision waiver requests.
Description: Rule Changes January 25, 2006
Document: ... quality of care violations. Chapter 193, Standing Delegation Orders. Amendments delete the reference to registration of delegation of prescriptive authority with the Board; set out rules requiring a physician who delegates prescriptive authority to document when and to whom a delegation is made; and ...
Description: Rule Changes January 09, 2005
Document: ... tudents. Repeal of chapter. Chapter 193, Standing Delegation Orders. Amendment to §193.6 regarding delegation of carrying out or signing of prescription drug orders to Physician Assistants and Advanced Nurse Practitioners.
Description: Rule Changes January 08, 2004
Document: ... es to the text of the rule. Chapter 193, Standing Delegation Orders. Amendments to §193.6 concerning the procedure for considering waiver requests for prescriptive delegation. Chapter 194, Non-Certified Radiologic Technicians. Amendments to §§194.1194.4, and 194.6; the repeal of §§194.7-194.10 and n ...
Description: Rule Changes January 02, 2013
Document: ... ent to §190.8 provides the standard for physician delegation of the performance of nerve conduction studies by individuals who are not licensed as physicians or physical therapists. The amendment to §190.14 amends the range and scope of sanctions for violations of the Medical Practice Act. CHAPTER 1 ...
Description: TEXAS STATE BOARD OF PHYSICIAN ASSISTANT EXAMINERS BOARD MEETING MINUTES AUGUST 1, 2002
Document: ... enda item #5, a report regarding the Prescriptive Delegation Waiver Advisory Committee, was next. Ms. Jaime Garanflo, Director of Customer Affairs, updated the board members regarding the work of the Prescriptive Delegation Waiver Advisory Committee, stating that there had been no recent waiver requ ...
Description: TEXAS STATE BOARD OF PHYSICIAN ASSISTANT EXAMINERS BOARD MEETING MINUTES AUGUST 1, 2003
Document: ... enda item #5, a report regarding the Prescriptive Delegation Waiver Advisory Committee, was next. Ms. Jaime Garanflo, Director of Customer Affairs, updated the board members regarding the work of the Prescriptive Delegation Waiver Advisory Committee, stating that there had been no recent waiver requ ...
Description: TEXAS PHYSICIANS ASSISTANT BOARD Physician Assistant Owned Clinics Ad Hoc Committee December 3, 2010
Document: ... uirements pertaining to physician supervision and delegation. Accordingly, a proposed amendment to Physician Assistant Board Rule 185.16 was drafted, adding Subsection 185.16(e) to permit PAs to own health clinics and contract with physicians to provide supervision under certain circumstances. A sta ...
Description: TEXAS PHYSICIAN ASSISTANT BOARD BOARD MEETING December 14, 2012
Document: ... Interim Committee report related to prescriptive delegation relationships between APN/PA's is yet to be filed. Key legislation dates were given. Staff will be tracking bills related to the board during the legislative session. Ms. Robinson gave a brief update on self direct semi independent status. ...
“... 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.