Prescriptive Authority
An Overview of APN Prescriptive Privileges in Texas
There are three primary limitations on prescriptive authority for APNs in Texas.
1) Prescriptive Authority must be delegated by a physician through a practice agreement protocol;
2) Physicians can only delegate prescriptive authority at certain types of practice sites; and
3) Controlled Substances are limited to Schedules III - V and certain limitations apply.
Sites that Qualify for Delegation of Prescriptive Authority
There are four designations for sites where physicians may delegate prescriptive authority to APNs or PAs.
- Medically underserved
- Facility-based practice
- Physician’s primary practice
- Alternate practice
In all these sites there are certain core supervision and documentation requirements.
The APN and delegating physician must:
- develop protocols;
- maintain a quality assurance process; and
- keep a log of dates an alternate physician assumes supervision in place of the delegating physician.
- In addition, the physician must be available when off-site for consultation, referral and assistance with emergencies.
- In any site in which the physician is not onsite the majority of the time, the APN must also keep a permanent record of the supervisory activities of the delegating physician (often referred to as a log).
- The physician must keep a permanent record of the APNs and PAs to whom the physician delegates prescriptive authority and the dates of that delegation.
Beyond these core requirements, each site differs in the qualifying criteria and the delegating physician’s supervisory duties.
Medically Underserved Sites (Sites Serving a Medically Underserved Population). A number of sites can qualify as medically underserved in both rural and urban areas. Some of these include federally designated rural health clinics; clinics in census tracks designated as a Medically Underserved Area (MUA) or a Health Professional Shortage Area (HPSA); and a public health or family planning clinic.
In a clinic designated as medically underserved, there is no limitation on the number of APNs or PAs to whom one physician may delegate prescriptive authority. However the physician is limited to delegating prescriptive authority at no more than 3 medically underserved sites that have combined operating hours of 150/week. The physician must be onsite once every 10 business days the APN is onsite, and a log must be kept of the physician’s activities while onsite. At a minimum, the physician must perform a review of 10% of patient’s charts and receive a daily report by telephone regarding any complications or problems not covered under the protocol.
Physician’s Primary Practice Sites. A physician’s primary practice site usually has one unifying concept. In most cases, the APN is seeing the physician’s patients. The APN may see these patients at a site where the physician spends the majority of time, a hospital, a long-term care facility, an adult daycare facility, the patient’s residence and/or, at one alternate site. In addition, a school-based clinic also qualifies under the physician’s primary practice site designation. With implementation of SB 532 on September 1, 2009, physicians who spend at least 50% of the time on site with an APN may also delegate prescriptive authority at any, or all, of three additional sites without any additional physician supervision: a site for established patients; charity care clinics where the APN volunteers; and disaster relief sites where the APN volunteers in a declared disaster or emergency.
A physician delegating prescriptive authority in a primary practice site may only delegate to a total of four APNs or PAs or their full-time equivalents (FTEs) and that includes the number of APNs and PAs to whom a physician delegates in any alternate sites. Other than the requirement for delegation protocols, a quality assurance process, and the physician availability by phone that apply to all practice sites, there are no specific physician supervisory requirements.
Alternate Sites. A physician may also delegate prescriptive authority to APNs and/or PAs in an alternate site where the physician spends 10% of the time with each APN on a monthly basis. The physician is limited to delegating prescriptive authority to no more than 4 APNs and/or PAs at the primary practice and alternate sites. The alternate site must be within 75 miles of the physician's primary practice or residence, and is limited to offering the same type of health care services as in the primary site. The physician must review 10% of charts and be available as needed by phone. Chart reveiws may occur offsite by electronic medical records.
Facility-Based Sites. Facility-based practices occur in two inpatient settings, licensed hospitals and long-term care facilities. In all these practices, the APN is limited to caring for patients admitted by the delegating physician unless another admitting physician grants permission for the APN to participate in the care. In other aspects, the law differs between facility-based practices in hospitals and long-term care facilities.
In hospitals, prescriptive authority may be delegated by the medical director, chief of medical staff, chair of the facility's credentialing committee, department chair, or by a physician who consents to a request from the medical director or chief of medical staff to delegate prescriptive authority to a APN that practices in that facility. There is no limitation on the number of APNs or PAs to whom one physician may delegate prescriptive authority in a hospital facility-based practice, but the physician may only delegate to APNs or PAs in one hospital.
In a long-term care facility-based practice, only the medical director may delegate prescriptive authority. The medical director may delegate prescriptive authority in a maximum of two long-term care facilities and to a maximum of four APNs and PAs (FTEs).
Options in Long-Term Care Facilities. APNs seeing patients in long-term care facilities have two options when choosing a site designation, a physician’s primary practice site or a facility-based site. Most physicians and APNs select the primary practice site because the APN is seeing the delegating physician’s patients. Because of the way the law is written, the physician does not have to be onsite with the APN at the long-term care facility the majority of the time (or any amount of time). If the APN is seeing several physicians’ patients in a nursing home, each physician may delegate prescriptive authority to that APN. Note that even with the primary practice site designation, the APN is probably going to be required to keep a log of the physician’s consultation and supervisory activities because the physician is not onsite the majority of the time.
The Site to Select if it Qualifies Under More Than One Designation. It is not unusual that one practice site qualifies under more than one type of designation. In that case, it is usually recommended to select the type of site designation that carries the least paperwork and supervisory requirements.
Controlled Substances
Physicians are limited in their legal authority to delegate prescribing for controlled substances. They may only delegate prescriptive authority for Schedules III - V and the following additional limitations apply:
1) Limited to a 90-day supply or less (or refills that equal a 90-day supply);
2) No refills after the initial 90-day supply without prior consultation with the physician;
3) No prescription for children under 2 years of age without prior consultation with the physician; and
4) Prior consultation must be noted in the chart.
APNs who prescribe controlled substances must have both a DPS controlled substances permit and a DEA number. For more information on the legal aspects of prescribing controlled substances and obtaining DPS and DEA numbers, see "Five Steps to Obtaining DPS and DEA Numbers."
Those who prescribe controlled substances should be aware of essential information provided on the Texas State Board of Pharmacy Website. SB 144 passed in 2007 required several state agencies, including the Board of Nursing, to produce a list of Web-based resources for practitioners who prescribe and handle medication with abuse potential. The resulting Webpage contains links to information on recognizing drug seeking behavior, appropriate pain managment guidelines, and much more essential information for prescribers.
Delegation and Termination of Prescriptive Authority Form
On November 27, 2009, the Texas Medical Board (TMB) adopted rules requiring all physicians who delegate or terminate prescriptive authority to notify the TMB. Physicians delegating or terminating prescriptive authority to an advanced practice registered nurse must complete and submit the form titled, "APN - Delegation of Prescriptive Authority." Instructions are included with the form. Click Here for additional information and a Q&A. Related informaiton is available on TMB's Website.
Other information on prescriptive authority is available by selecting articles listed on the right navigation bar. For comprehensive information, purchase A Guide for APN Practice in Texas. This 324-page manual contains a sample Practice Agreement Protocol. CNAP's Sample Practice Agreement Protocol may also be purchased separately. Any APRN prescribing controlled substances for pain should be familiar with essential information provided on the Texas State Board of Pharmacy Webpage.
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