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“... 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. ”
“... physicians, and 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 ... ”
“... ontrolled substances, or delegate medical acts or prescriptive authority.
Provisional License is available only to applicants for a full medical license and allows the applicant to practice for 270 days in a medically underserved or health professionals shortage area.
Medical License Limited to Unde ... ”
“... ce of the expiration 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 prac ... ”
“... this considered a facility-based practice?
Is a prescriptive authority agreement required in a hospital or long term care facility-based practice?
At how many facilities can one physician delegate prescriptive authority through protocols?
Who may delegate prescriptive authority in a hospital f ... ”
“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 ... ”
“... ) SUPERVISION & PRESCRIPTIVE DELEGATION REGISTRATION
If you have questions regarding the log in for the Supervision and Prescriptive Delegation Registration System, please use the “HELP” options available in the the upper right hand corner on each ... ”
“... to a patient.
For additional FAQs on prescriptive delegation, visit: http://www.tmb.state.tx.us/page/prescriptive-delegation
”
“... spital privileges, specialty board certification, delegation information, etc.)and some of which is provided and verified by the board (e.g., license status, educational background, disciplinary actions, etc.):
(1) Full name;(2) Place of birth if the physician requests that it be included in the phy ... ”
“... spital privileges, specialty board certification, delegation information, etc.) and can be updated at any time. Many updates are provided by the physician at a time of licensure renewal/registration. An update may be provided by the licensee between renewals, while certain updates MUST b ... ”
“... r tests, and prescribe.
Supervision and Prescriptive Authority Registrations: waived the requirement of physicians having to register with the TMB their supervision and prescriptive authority for PAs and APRNs.For more information on this requirement, visit: https://www.tmb.state.tx.us/pag ... ”
“At this time, the Online Supervision and Prescriptive Delegation Registration system is not set up to accept delegation locations outside of Texas.
Any physician, PA or APRN who does not have a TX practice address and needs to register prescriptive delegation, please contact the Registration Departm ... ”
Description: PA Board 2002 January, Full Board Min
Document: ... blication of the proposed rule change relating to delegation of prescriptive authority at alternate sites and stated that the comments had been reviewed by the Long Range Planning Committee. Based on the comments, staff recommended incorporating additional amendments to the rule. Dr. Patrick and Ms. ...
Description: PA Board 2002 January, Long Range Plan Min
Document: ... blication of the proposed rule change relating to delegation of prescriptive authority at alternate sites. Based on the comments, staff recommended incorporating additional amendments to the rule. Dr. Patrick and Ms. Shackelford explained that this was an informational item only and that the rule wo ...
Description: PA Board 2009 July, Full Board
Document: ... ealth program and SB532 relating to a physician's delegation of prescriptive authority to physician assistants. After discussion, the board directed staff to research and draft guidelines to address the supervision of a physician assistant when the physician assistant is the employer of the physicia ...
Description: PA Board 2009 July, Licensure Committee
Document: ... of the Board. Mr. Rahr then asked if the issue of prescriptive authority of PAs on temporary licenses for out of practice issues be discussed. It was determined that the Committee would evaluate the issue on a case by case basis.
Michael A. Mitchell, D.O. entered the meeting.
Agenda Item 2 Discuss ...
Description: PA Board 2004 July, Full Board
Document: ... edical Board meeting concerning electromyography, prescriptive medical devices, and the scope of practice in the area for physician assistants. The Board directed staff to present their expressed concerns with 193.12 at the next Medical Board meeting.
Agenda item #4, report regarding the Prescripti ...
Description: PA Board 2008 July, Full Board Minutes
Document: ... report on several of the complex issues regarding prescriptive medical device rules. Agenda item #4, Discussion, recommendation, and possible action regarding supervision of physician assistants by physicians with restrictions on their licenses. After discussion, the board directed staff to draft pr ...
Description: PA Board 2008 July, Licesure Committee
Document: ... on, recommendation, and possible action regarding delegation of authority to the Executive Director in cases of mental health, physical health, substance abuse, and submission of false statements or documents during the licensure process to offer orders. Ms. Garanflo presented a proposal to delegate ...
Description: PA Board 2009 March, Full Board
Document: ... gislative bills relate to the physician assistant delegation and she gave an update on SB9397. Ms. Robinson reported that the board does not take a position on legislation and will do what the legislature directs. Agenda item #6, Budget Report. Ms. Robinson gave a budget report. Agenda item #7, Cons ...
Description: PA Board 2002 November, Full Board Min
Document: ... lishments. Agenda item #4, 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. A list of the committee members was ...
Description: PA Board 2002 November, Lic Min
Document: ... Mr. Speer explained that physicians can delegate prescriptive authority to an unlimited number of Advanced Practice Nurses in a hospital setting but are limited to the number of physician assistants they can delegate to in the same setting. The consensus of the committee was to report this item to ...
Description: PA Board 2003 November, Full Board
Document: ... Department. Agenda item #4, report regarding the Prescriptive Delegation Waiver Committee requests and proposed changes to board rules 193.6 concerning applications for waivers and meetings of the Waiver Committee, was next. Ms. Garanflo gave a report on proposed changes that will be considered for ...
Description: PA Board 2004 November, Full Board
Document: ... re in Texas. Agenda item #4, report regarding the Prescriptive Delegation Waiver Committee requests and recommendations. There were no items to report.
Agenda item #6, consideration and approval of Agreed Board Orders. Dr. Hedges moved, Ms. Clark seconded, and the motion passed to approve the agree ...
Description: PA Board 2005 November, Full Board
Document: ... ed changes to Chapter 193.2 Definitions and 193.6 Delegation of the Carrying Out or Signing of Prescription Drug Orders to Physician Assistants and Advanced Practice Nurses. Agenda item #4, Report of the Physician Assistant Workgroup meeting and presentation and discussion of draft rules. Ms. Shacke ...
Description: PA Board 2007 November, Full Board Minutes
Document: ... isallowing the physician assistant from delegated prescriptive authority as well as requiring ten hours of CME in the area of alcohol and drug awareness. Ms. Welch seconded the motion. The motion passed.
Ms. Chapman gave a report of the Disciplinary and Ethics Committee Meeting. Ms. Chapman moved, ...
Description: PA Board 2007 November, Licensure Committee
Document: ... restrictions: the applicant may not be delegated prescriptive authority; the applicant must take 10 hours of ethics CME approved by the Executive Director, and 10 hours of drug and alcohol awareness CME approved by the Executive Director; the applicant may work only in a setting that provides conti ...
“... 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.
“... 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.
“... endent authority to administer anesthesia without delegation by a physician.” (Page 5). Since the selection and administration of anesthesia is a medical act, CRNAs must be properly delegated this act by a physician. A CRNA who administers anesthesia without proper delegation from a ... ”
Are CRNA’s authorized to practice independent of physician supervision and delegation?
No, neither the Medical Practice Act nor the Nursing Practice Act authorize independent practice by a CRNA. Additionally, Texas Attorney General Opinion No. KP-0266 found “A certified registered nurse anesthetist does not possess independent authority to administer anesthesia without delegation by a physician.” (Page 5). Since the selection and administration of anesthesia is a medical act, CRNAs must be properly delegated this act by a physician. A CRNA who administers anesthesia without proper delegation from a physician would be liable for the unlicensed practice of medicine.
“... m. If there is a change to the scope of the delegation, physicians must notify the Board within 30 days of this change.PAs are likewise required to register their supervising physicians with the Board prior to beginning to practice under the employment or prescriptive authority agreement. ... ”
Do I have to let the Medical Board know about my delegates/supervising physicians?
Yes, if you are a physician or a physician assistant.
Physicians are required to register all PAs and APRNs that they supervise prior to the delegates beginning to work for them. If there is a change to the scope of the delegation, physicians must notify the Board within 30 days of this change.
PAs are likewise required to register their supervising physicians with the Board prior to beginning to practice under the employment or prescriptive authority agreement. They are also required to notify the Board within 30 days of any change to the scope of the delegation.
APRNs should look to guidance provided by the Texas Board of Nursing for how to register their delegating physicians, as the Medical Board does not have licensing authority for nurses.