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What constitutes a license that is in good standing for purposes of entering a prescriptive authority agreement?
Do I have to disclose information regarding investigations and discipline? If so, to whom must this information be disclosed
What must be included in a prescriptive authority a ... ”
“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. ”
“... that the individual is currently licensed in good standing in another state and has current orders assigning the servicemember to Texas. The recognition, once approved, is only the ability to practice while in Texas on assignment, but it is not a Texas license.
The law includes the following ... ”
“... e. This database will provide links to view Board Orders for most licensees, where applicable.
We also have an online verification system that allows registered health care entities to receive limited information on open investigations, if any exists. To access this database, choose the ... ”
“... dified or rejected by the full Board. The Board's standing committees consist of the following:
Executive Committee
Duties consist of the following: review Board meeting agendas; ensure records are maintained of all committee actions; delegate tasks to other committees; take action on urgent matters ... ”
“... 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 ... ”
“... cers, work to ensure licensees under disciplinary orders from the Board comply with terms of the orders.
Phone: (512) 305-7098
Fax: (888) 661-4973 ”
“... f Emergency Physicians, Texas Association of Free-Standing Emergency Centers, National Association of Free-Standing Emergency Centers and the American Medical Association. Dr. Ho is also an Eagle Scout and the proud father of three.
Lawrence G. "Larry" Hughes, Ed.D.
Lawrence G. "L ... ”
“... 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.
... ”
“... 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 ... ”
“... ofiles and provides links to view Board Orders, where applicable).
Non-Profit Health Organizations
Chief Medical Officer Designation
Electronic Death Certificate
Jointly Owned Physician / PA
Institutional Review Board (IRB) Annual Report
”
“... ilable to a physician who is licensed and in good standing, or was licensed and retired in good standing, as a physician in another state; and is or was authorized as a physician to treat personnel enlisted in a branch of the United States armed forces or veterans.
The Military Volunteer License:
a ... ”
“... 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 screen. ... ”
“... ule, by submitting documentation of protocols and standing orders upon request; and
appropriate safeguards exist for patient care and adequate supervision of all EMS personnel under the physician's supervision.
To request a waiver to hold the position of off-line medical director for more th ... ”
Description: Rule Changes September 14, 2003
Document: ... nd continuing 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: ... d anesthesia rules 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 September 01, 2009
Document: ... Texas Physician Health Program and Rehabilitation Orders , with the Repeal of §180.1, relating to Rehabilitation Orders. The New Rule §180.1, Purpose, establishes the statutory authority and the purpose for the Texas Physician Health Program and the use of rehabilitation orders. The New Rule §180.2, ...
Description: Rule Changes August 10, 2008
Document: ... le of Chapter 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, Delegat ...
Description: Rule Changes July 03, 2007
Document: ... .7, to establish a procedure for cease and desist orders.
Description: Rule Changes July 02, 2000
Document: ... , regarding licensure documentation. Chapter 193, Standing Delegation Orders - new §193.9, regarding pronouncement of death.
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 May 09, 1999
Document: ... notice of 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: ... compliance. 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 May 02, 2010
Document: ... edings for the Modification/Termination of Agreed Orders and Disciplinary Orders, will prohibit probationers from requesting modification/termination of an order if the probationer is under investigation for alleged noncompliance with the order, and clarifies that modification/termination requests m ...
Description: Rule Changes March 03, 2010
Document: ... Texas Physician Health Program and Rehabilitation Orders: new amendments §180.4, Operation of Program, relating to Operation of Program, which establishes the requirements for eligibility, referrals, drug-testing, and fees for the Physician Health Program. http://www.sos.state.tx.us/texreg/archive/M ...
Description: Rule Changes March 08, 2001
Document: ... and insufficient 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 07, 2002
Document: ... ect a citation error. Chapter 180, Rehabilitation Orders. Repeal of §180.1 and new §180.1 regarding the purpose of rehabilitation orders and the factors to be considered when proposing and determining eligibility for a rehabilitation order. Chapter 181, Contact Lens Prescriptions. Rule review and am ...
Description: Rule Changes March 06, 2003
Document: ... for general clean-up of the chapter. Chapter 193, Standing Delegation Orders. Amendments to '193.6 regarding supervision waiver requests.
Description: Rule Changes February 28, 2011
Document: ... o Written Answers in SOAH Proceedings and Default Orders, amends the process for issuance of default orders. Under the proposed language, if a licensee fails to timely file a response in a SOAH case, SOAH may at Board staff's request, remand the case to the Board and the Board will then rule on the ...
“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.
“No. Free standing clinics, centers or other medical practices that are owned or operated by or associated with a hospital or long term care facility that are not physically located within the hospital or long term care facility are not considered facility based practices. Prescriptive au ... ”
If I work in a clinic owned by the hospital, is this considered a facility-based practice?
No. Free standing clinics, centers or other medical practices that are owned or operated by or associated with a hospital or long term care facility that are not physically located within the hospital or long term care facility are not considered facility based practices. Prescriptive authority agreements are required in these settings.
“... 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.
“... 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 anesthe ... ”
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.
“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. Auth ... ”
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.