Sample Facility-Based Protocol Packet
Facility-Based Protocol...........................................................1
Practice Notes & Examples ....................................................3
Last Updated December, 2019
NOTICE: Texas Nurse Practitioners (TNP) provides this information with the express understanding that 1) no attorney-client
relationship exists, 2) neither TNP nor its attorneys are engaged in providing legal advice and 3) that the information is of a
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is complete, accurate and timely, TNP cannot guarantee the accuracy and totality of the information contained in this
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Any legal forms are only provided for the use of physicians in consultation with their attorneys.
Facility-Based Protocol
A facility-based protocol is a written authorization whereby a physician delegates authority to an
Advanced Practice Registered Nurse (APRN) to initiate medical aspects of patient care, including
delegation of the act of prescribing or ordering a drug or device at a facility-based practice.
General Provisions
This Facility-Based Protocol is between the physician and the Advanced Practice Registered Nurse
(APRN) listed below. The physician and APRN hereby acknowledge that the APRN’s practice under this
agreement is restricted to a single hospital or licensed long-term care facility. This delegation
authorization has been developed in accordance with policies approved by the facility’s medical staff
or a committee of the facility’s medical staff as provided by the facility bylaws. This Agreement shall be
reviewed, dated, and signed by the parties to the Agreement at least annually and shall be maintained
in the practice setting. Amendments must be written and signed by the parties.
Identification of Parties
Physician: ____________________________________
Physician is the: (mark one)
☐ Medical director or chief of medical staff of the facility
☐ Chair of the facility’s credentialing committee
☐ Department chair of the APRN’s facility department
☐ Physician who consents to the request of the
Medical director or chief of medical staff to
delegate prescriptive authority to the APRN
Advanced Practice Registered Nurse: ____________________________________
The following may be prescribed:
☐ All dangerous drugs (non-scheduled)
☐ All schedule III-V (within the restrictions defined by 22 Texas Administrative Code (TAC) §222.8(b))
☐ All schedule II (for patients meeting the requirements of 22 TAC §222.8(c))
Limitations: _________________________________________________________________________
Alternate supervising physician(s):
Name
Signature
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
This Agreement is entered into and signed on this date: _________________________________
Physician Signature: _______________________ APRN Signature: ___________________________
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Annual Review:
Date of Review
Physician Signature
APRN Signature
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Pursuant to Section 160.007 of Texas Occupations Code, Texas Health & Safety Code 161.032 and 42 USC Sec. 11101 et
seq., this information is confidential & privileged.
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Practice Notes & Examples
The information below is intended to provide general guidance on filling out the Facility-Based Protocol
in this packet. Keep in mind that the language below is merely general guidance. These should be
individualized to address the particular needs of the APRN’s practice, including the APRN’s experience,
office procedures and patient population. Please review the legal disclaimer on the cover page of this
packet prior to using any of the suggested language, as it applies throughout.
General Notes:
Protocols need not describe the exact steps that an APRN must take with respect to each specific
condition, disease, or symptom. Supervision must conform to what a “reasonable, prudent physician
would find consistent with sound medical judgment” and may vary based on the experience of the
APRN. Protocols or other written authorization should promote the APRN’s ability to exercise
professional judgement and be in alignment with the APRN’s experience and education. Continuous
supervision is required; however, constant physical presence of the physician is not required.
Additionally, APRNs with prescriptive authority are required to complete additional continuing
education hours. Be sure to check the Board of Nursing webpage to determine which requirements
apply to you.
Facility based prescriptive delegation may not permit the prescribing or ordering of a drug or device
for the care of patients of any other physician without the prior consent of that physician. This
consent may be obtained in many different methods, such as policies within a group practice,
contracts between the facility and the physician group or a simple form, signed by the physicians,
indicating their approval for the APRN to prescribe for their patients under the designated physician’s
delegation.
Physicians may delegate to an unlimited number of APRNs via a facility-based delegation in a
hospital; however, they may only use a facility-based delegation at a single hospital or two licensed
long-term care facilities. Delegation at a long-term care facility is limited to the Medical Director of
the facility and is limited to a maximum of seven full time equivalents for APRNs and physician
assistants. Use of a facility-based delegation does not prevent the physician from also delegating at
other sites using a prescriptive authority agreement.
The following may be prescribed:
Practice Note: In most cases, and especially if experienced, there should not be any limitations on
the types of drugs that the APRN may prescribe. However, in some circumstances, it may be
preferable to limit prescribing to only pharmaceuticals in broad types or categories. For example:
antidepressants, oral contraceptives, antihypertensive agents, antibiotics, antiviral agents,
medications to treat fibromyalgia, etc. It is recommended that individual names of drugs not be
noted.
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