Presented by:
Mildred L. Johnson, J.D., CPC, CCEP
Case Studies by Todd Bell, M.D.
Assistant Professor, Departments of Internal Medicine
& Pediatrics
OBJECTIVES
 Identify the requirements under Texas laws & rules for
physician delegation of prescriptive authority to an
Advance Practice Nurse (APN) or Physician Assistant
(PA).
 Define the scope of physician delegation of prescriptive
authority
 Develop & Maintain Written Protocols as required by
Texas law.
General Premise
 Tex. Occ. Code, Chapter 157.001
 Physicians may delegate medical acts under specific
conditions.
 Tex. Occ. Code, Chapter 157.002
 Physicians may delegate administration and provision
of dangerous drugs
 Tex. Occ. Code, Chapter 157.051 et. seq.
 Physicians may delegate the carrying out or signing of
certain prescription drug orders to an APN or PA.
Ambulatory Clinic Policy 4.11
 General Outline of Legal & Regulatory Standards for
Physician Delegation of Prescriptive Authority
 Applies to TTUHSC physician delegation of
prescriptive authority to TTUHSC APN or PA
 Identifies responsible persons for compliance with
legal requirements.
When Does it Apply?
 Physician delegates authority to a APN or PA
 Pursuant to a written protocol
 To carry out or sign a prescription drug order for
 Dangerous drug or Controlled Substances, Sched. III-V.
 Which is registered with the Texas Medical Board
(TMB)
The Written Protocol - Content
 Lists the types/categories of drugs available for
prescription, limitations on number of dosage units
and refills permitted & instructions to be given to the
patient for follow-up;
OR
 Lists the types/categories of drugs that may not be
prescribed.
Attachment “A” (Handout)
The Written Protocol
 Agreed to & Signed by Physician and ANP/PA
 Reviewed and Signed Annually
 To be scheduled by Department Administrator
 Maintained on Site
 Responsibility of the Department Administrator
 Includes all current and past protocols.
TMB Registration
 Must Register with Texas Medical Board (TMB),
effective 1/31/10
 Online Registration Process
 Hard copy supervision and delegation forms WILL NOT
be accepted as of 8/1/10 subject to some exceptions

Temporary Physician/Temporary PA or Faculty Temporary
License – contact the PRC at 512-305-7030
 Verify Registration through TMB Verification site;
Print and File with the Written Protocol.
Delegation – The “Drugs”
 Dangerous Drugs
 Controlled Substances, Schedules III-V
 Prescription, including refills cannot exceed 90 days
 Physician must be consulted before refill which must be
documented in the medical record
 Physician must be consulted before prescribing
controlled substance to children < 2 years, which must
be documented in the medical record.
Prescription Requirements
 Patient’s Name and Address
 Drug to be Dispensed
 Directions to the patient for taking the drug
 the dosage (and intended use, if appropriate)
 The Name, Address, phone number of the Physician;
 The Name, Address, phone number & ID number and
signature of the APN/PA completing/signing the order
 The date; and
 The number of refills permitted
Alternate Supervising Physician
 A physician who provides supervision during
temporary absence of delegating physician
 Written Affirmation From Alternate Physician
 That he/she is familiar with written protocol
 That he/she is accountable for adequately supervising
prescriptive delegation pursuant to the written protocol
 Contains dates of supervision & signed by alternate
physician
 Written Affirmation maintained with written protocol
Delegation - Sites
 Requirements for supervision & documentation vary
depending on the practice site:
 Medically Underserved Populations (MUP)
 Primary Practice Site
 Alternate Practice Site
 Facility Based Practice
MUP Locations
 Definition of MUP – Tex. Occ. Code, Sec. 157.052, et. seq
 Located in a medically underserved area;
 Located in a health manpower shortage area
 Rural health clinic
 A public health clinic or a family planning clinic under
contract with Texas DHS or DOH
 Located in an area determined by Texas DOH to have
insufficient number of physicians or serves a
disproportionate number of clients eligible to participate
in federal/state/local health care programs.
MUP – Requirements
 Physician Supervision Limitations
 Cannot supervise > 3 clinics without waiver from TMB
 Cannot supervise any number of clinics with combined
regular business hours > 150 concurrent hours/week
without waiver from TMB
 Not more than 5 PAs (Silent as to number of APN).
 Written Quality Assurance Plan On-Site
 Department Administrator to Verify
MUP – Site Visits/Chart Reviews
 Physician Site Visit Requirements
 On-site at least once every 10 business days while
APN/PA is on-site
 Responsibility of Department Administrator to schedule
 Physician Chart Review
 Random Review and Countersignature of at least 10% of
patient charts during on-site Visit
MUP – Physician Supervision
 Responsible for formulation/approval of orders or
protocols
 Receives daily status report on any problem or
complication encountered; and
 APN/PA Responsible for communicating daily status
reports, as applicable
 Available by phone/e-mail for consultation, patient
referral or assistance with medical emergency
MUP – Written Log
 Created by APN/PA and SIGNED by Physician at end of
each site visit
 Names or ID number of patients discussed during the
daily status reports (if any)
 Dates/times when physician was on site;
 Summary of what physician did while on-site to
include:
 a description of the quality assurance activities
conducted
 Patients seen or whose case histories were reviewed with
the PA/APN
CASE STUDY #1
 Question: An internist supervises a PA working at a clinic
that serves migrant farm workers. At the end of the day, the
PA and physician sit down to discuss ways to change a
patient intake form to ensure preventive medical services
are offered to appropriate patients. They summarize their
conclusions in writing and the physician signs the
document. Does this fulfill the quality assurance
requirement for this clinic?
 Answer: No. Although a worthwhile endeavor, and
undoubtedly helpful for quality improvement, this project
does not insure the delivery of care is in compliance with
the clinic’s written quality assurance plan.
Primary Practice Site
 Practice Location where Physician spends majority of
physician’s time (>50%)
 A licensed hospital, long-term care facility or adult
care center where the physician and PA/APN are
authorized to practice
 Public School District clinic
 Patient’s Residence
 Another location where the physician is physically
present with the PA/APN
Primary Site - Supervision
 Limit on Number of PA/APN Supervised
 Cannot supervise more than four PAs or APNs or their
full-time equivalent at primary practice site and
alternate practice sites, combined
 No required site visits or chart reviews
 Continuous Supervision, but not constant physician
presence
 Must confirm to what a reasonable prudent physician
would find consistent with sound medical judgment,
varied based on APN/PA’s experience.
Primary Site – Other Items
 Patient Relationships
 Must have established or will establish a physicianpatient relationship with the patient
 Alternate Supervising Physician is allowed on a
temporary basis
CASE STUDY #2
Dr. Jones and Mr. Smith, ANP work together in a pediatric
practice. Mr. Smith sees a 19 month old child sent from
the ER after suffering a seizure. After assessing the
patient, Mr. Smith determines the patient would likely
benefit from valproic acid anti‐epileptic therapy. The
patient is also prescribed rectal diazepam for recurrence
of prolonged seizures. He schedules the patient to return
to clinic in 4 weeks to see either himself or Dr. Jones.
CASE STUDY #2
 Question: In this scenario, is the mid‐level provider
obligated to document any consultation or
involvement by the supervising physician in this
patient’s chart?
 Answer: Yes. Although the evaluation of seizures in
children may be within the scope of practice of the
ANP, he is not allowed to prescribe diazepam (a
controlled substance) to a child under age 2 without
consulting his supervising physician.
CASE STUDY #2
 Question: The board requires that mid‐level providers
functioning at a primary practice site see patients who
have or will have a relationship with the supervising
physician. Within what time period does Dr. Jones
have to see the patient personally to satisfy that
requirement?
 Answer: No time frame is specified by the board.
Alternate Practice Site
 Site were services similar to those provided at
physician’s primary site are provided; and
 Less than 50% of physician’s time is spent at the site
(i.e., not a primary practice site); and
 Site is located within 75 miles of delegating physician’s
residence OR primary practice site.
Alternate Practice - Supervision
 Limitations on Number of PA/APN Supervised
 Cannot supervise more than four PAs or APNs or their
full-time equivalent at primary practice site and
alternate practice sites, combined
 Physician Site Visits
 Delegating Physician is on-site at least 10% of hours of
operation of the site each month.
 Department Administrator responsible for scheduling.
Alternate Practice - Supervision
 Physician Chart Reviews
 Reviews at least 10% of medical charts for each APN or
PA at the site

Can be from a remote location for EHR
 Available by phone/e-mail for consultation, patient
referral or assistance with medical emergency
Alternate Practice – Written Log
 Created by APN/PA and SIGNED by Physician at end of
each site visit
 Names or ID number of patients discussed during the
daily status reports (if any)
 Dates/times when physician was on site;
 Summary of what physician did while on-site to
include:
 Patients seen or whose case histories were reviewed with
the PA/APN
CASE STUDY #3
 Question: A physician operates a busy primary care
practice in one town and supervises an ANP at a clinic in
nearby small town where the physician lives. The
physician goes to the alternate practice site in the evening
to review charts and do paperwork. In a typical week, she
spends 6‐7 hours in the evening at the clinic. Has the
physician met supervisory requirements?
 Answer: No. Although the physician has spent 6‐7 hours
per week at the clinic, she has not been at the clinic 10%
of the time that the clinic was open and the ANP was
seeing patients.
Facility – Based Location
 Sites
 Hospital

Not more than 1 and unlimited number of APN/PA
 Long term care facility

Not more than 2 and not more than 4 APN/PA
 Delegating Physician Must Hold Specific Facility Position
 Medical Director (LTCF only) or Chief of Medical Staff or
a physician designee who has agreed
 Chair of Facility’s Credentialing Committee
 Department Chair of a Facility Department
Facility – Based
 Delegation under:
 Physician’s Order;
 Standing Medical Order or delegation order; or
 Protocol developed in accordance with policies approved
by facility’s medical staff or its committee
 Delegation must occur in the Facility
 Cannot be for treatment/care of other physician’s
patients without the other physician’s consent.
 Continuous Supervision, but Physician Presence not
required.
TERMINATION OF RELATIONSHIP
 Notification Provided to the respective Boards
 Names of each party
 License numbers of each party
Delegation to CRNA
 Location: Licensed Hospital or ASC
 Delegation: Ordering of drugs and devices necessary
for a CRNA to administer an anesthetic or an
anesthesia-related service ordered by the physician.
 Pursuant to the order and in accordance with facility
policies or medical staff by-laws, the CRNA may select,
obtain and administer those drugs and apply the
appropriate medical devices necessary to accomplish the
order and maintain the patient within a sound
physiological status.
Delegation for OB Services
 Delegation to:
 PA offering OB services and certified by the TMB as
specializing in obstetrics; or
 APN recognized by Texas BON as a nurse midwife
 Delegation of act/acts of administering or providing
controlled substances to the nurse midwife’s or PA’s
patient during intra-partum and immediate postpartum care.