Quick Facts for APRN Practice in Texas
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APRNs will have two license numbers one for RN and second for APRN. Both must be current to
practice. Must have a valid RN license to get APRN license (or privilege to practice as RN thru
Nurse Licensure Compact). For APRNS with more than one title as APRN (CNS and NP for
example) must apply and be licensed in both specialties to use title but all APRN titles/license
will be linked to a single APRN license number. APRN license can be verified online with either
RN or APRN license number
o New certificate with new license number will be sent following the APRN’s next renewal
of license
Identification.
o APRN, APN are not designated titles and should not be used as part of the APRN’s
credentials at this time. BON is planning to update rules to allow use of “APRN” to
denote licensure. Until the rule is changed APRNs must use RN to denote licensure and
then advanced practice role and population-focus as the designated advanced practice
title, PNP, FNP, CRNA, ACNS, etc…
o Previous umbrella term in statute was Advanced Practice Nurse. In 2008 BON started
changing rules to term APRN and as of 11/1/13 Advanced Practice Registered Nurses
was enacted in statute (section 301.152, Texas Occupations Code). The definition reads:
 “Advanced practice registered nurse” means a registered nurse licensed by the
board to practice as an advanced practice registered nurse on the basis of
completion of an advanced educational program. The term includes a nurse
practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialists. The
term is synonymous with “advanced nurse practitioner” and “advanced practice
nurse”
o §221.11. When providing advanced practice nursing care to patients, the advanced
practice nurse shall wear clear identification which indicates the individual is a
registered nurse with the appropriate advanced practice designation authorized by the
board.
o § 221.2(b) A registered nurse who holds current authorization to practice as an
advanced practice nurse issued by the board in any of the categories indicated in the
previous subsection shall use that title when functioning in the advanced practice role. A
registered nurse who was granted authorization to practice in an advanced role and
specialty not indicated in the previous subsection prior to January 1, 2006, may continue
to use the advanced practice title approved by the Board provided all requirements for
maintenance of advanced practice authorization are met. "Advanced practice nurse"
shall not be used as a title.
Continuing Education Requirements
o Senate Bill 1058 requires nurses to complete 2 contact hours in nursing jurisprudence
and ethics prior to every 3rd licensure renewal cycle (2 hours every 6 years). May not be
met through an approved national certification. Content must include TX Nurse Practice
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Act, TX BON rules including Board Rule 217.11, standards of nursing practice, Texas BON
position statements, principles of nursing ethics and professional boundaries
 BON has 2 continuing education offerings which meet this requirement.
Workshop titled “Protecting Your Patients and Your practice” and interactive
online CNE Opportunity titled “Nursing Regulations for Safe Practice”.
 Online course may be found at https://www.bon.texas.gov/catalog
o Nurses who provide care to older patients (not defined) must complete 2 contact hours
related to older adult or geriatric care every renewal cycle. Content must include elder
abuse, age related memory changes and disease processes and end of life issues.
National nursing geriatric certification satisfies this requirement.
o Any nurse who performs forensic examination on a sexual assault survivor in any
practice setting must have basic forensic evidence collection training or equivalent
education before performing exam. ED nurses must complete 2 contact hours related to
forensic evidence collection within 2 years of initial date of employment. One time
requirement.
o Every 2 year renewal cycle must complete 20 CE hours or proof of national certification
 APRNs with prescriptive authority must have 15 CEs in pharmacotherapeutics
 APRNs with controlled substance privileges must get an additional 3 CEs related
to CS.
 1 contact hour = 1 category CME. One semester credit = 15 CE hours (nursing
relevant)
 CE program must be approved by one of BON recognized CE accrediting
agencies. Following are recognized agencies applicable to APRN practice
 American Association of Nurse Practitioners
 ANA/ANCC
 AACN
 American Association of Nurse Anesthetists
 American College of Nurse-Midwives
 Category 1 CME
 Colleges and Universities
 Other State Boards of Nursing
o Required to keep record of CE for minimum of 2 renewal periods (4 years) in case of
audit
Prescriptive authority
o SB406 – removed some restrictions (not really effecting facility based), provided
clarification in terminology such as what constitutes facility based, also made some
things that have always been rules/regulations more obvious
 Ex: clarified that prescriptive authority includes authority to order drugs and
medical devices
o Prescriptive authority is required to order durable medical equipment (DME)
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Must keep certain permanent records at practice and retain records for 2 years after
termination of agreement. Recommended to keep all documentation related to
delegation (including agreements, quality meetings, etc.) for these length of time
o One or more alternate physicians may be designated in PAA/protocol to assume quality
assurance and consultation duties when the delegating physician is out of town or
otherwise unavailable. This is not required. Designated physicians are not required to
register with TMB or sign PAA/protocol.
o PAA/protocols do not need to describe exact steps that APRN must take and should be
written so APRN may use education and judgment in order to provide care for patients
 APRN protocol is not to be confused with protocols that are used to describe
specific steps to treat patients with certain S&S or undergoing a particular
procedure
o Current law does not technically require APRNs to have a delegating physician who is
appropriate for all the patients the APRN sees in their practice. However, APRN is
expected to create a safe environment and legally and ethically obligated to ensure that
a mechanism for consultation and referral exists. This can be done by finding one or
more physicians who are willing to consult the APRN regarding those patients outside
the delegating physician’s scope. Advisable to get some type of written agreement with
physicians who agree to consult and refer, delegation of prescriptive authority
agreement is even better.
o If one of the individuals in the PAA/protocol becomes the subject of an investigation by
respective licensing board, the individual shall immediately notify the other party
o Prior to executing PAA all parties must disclose any prior disciplinary action taken by
their respective licensing board
o QAI can include adding APRNs to all already existing QAI process for physicians.
o PAA or protocol: Okay to say APRN may prescribe/order all dangerous drugs. If a list of
drugs allowed to prescribe is included then it must include limitations on number of
dosages units, refills permitted and instructions to be given to the patient for follow-up
monitoring. An exclusionary list only requires listing of drugs not to be ordered or
prescribed.
Prescriptions
o Delegating physician is responsible for devising and enforcing a system to account for
and monitor the issuance of prescriptions under the physician’s supervision
o §222.4. Minimum Standards for Prescribing or Ordering Drugs and Devices.
http://www.bne.state.tx.us/rr_current/222-1.asp
o (a) The APRN with full licensure and a valid prescription authorization number shall:
 (1) order or prescribe only those drugs or devices that are:
 (A) authorized by a prescriptive authority agreement or, if practicing in a
facility-based practice, authorized by either a prescriptive authority
agreement or protocols or other written authorization; and
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(B) ordered or prescribed for patient populations within the accepted
scope of professional practice for the APRN’s license; and
 (2) comply with the requirements for chart reviews specified in the prescriptive
authority agreement and periodic face to face meetings set forth in the
prescriptive authority agreement; or
 (3) comply with the requirements set forth in protocols or other written
authorization if ordering or prescribing drugs or devices under facility-based
protocols or other written authorization.
o (b) Prescription Information. The format and essential elements of a prescription drug
order shall comply with the requirements of the Texas State Board of Pharmacy. The
following information must be provided on each prescription:
 (1) the patient’s name and address;
 (2) the name, strength, and quantity of the drug to be dispensed;
 (3) directions to the patient regarding taking of the drug and the dosage;
 (4) the intended use of the drug, if appropriate;
 (5) the name, address, and telephone number of the physician with whom the
APRN has prescriptive authority agreement or facility-based protocols or other
written authorization;
 (6) address and telephone number of the site at which the prescription drug
order was issued;
 (7) the date of issuance;
 (8) the number of refills permitted;
 (9) the name, prescription authorization number, and original signature of the
APRN who authorized the prescription drug order; and
 (10) the United States Drug Enforcement Administration numbers of the APRN
and the delegating physician,if the prescription drug order is for a controlled
substance.
o APRNs do not have the authority to delegate an agent to orally communicate
prescriptions to pharmacy for APRN. (may not delegate something this is delegated to
you)
 May be done if delegating physician designates one or more LVN/RN to perform
this task.
 RN/LVNs permitted to call prescriptions to the pharmacy must be designated in
the practice protocol or in written document that is maintained on site. This
must be made available to any pharmacist that requests the name(s).
 This should only be used as a last resort
Controlled substance
o Control substances limitations
 Limit quantity to 90 day supply or refills totaling a 90-day supply
 Consult with physician and note the consultation in the chart prior to:
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Refilling the controlled substance (additional prescription for the same
controlled substance for same individual)
Prescribing a controlled substance for any child less than 2 years of age
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Schedule II
 APRNs have been able to order schedule II drugs on hospitalized inpatients
under a “standing medical order”. SB 406 allows physicians to delegate “order
and prescribing” of schedule II drugs if allowed by facility medical staff bylaws
and policies for facility based and hospice APRNs only. Non-facility based must
continue to use SDMO and can’t write a prescription for discharge (Woolbert, pg
102).
 Prescription may not be called to a pharmacy
 Must be written on official prescription
 Quantity must be written using both the numerical and written number
 For more information and to order official pads:
http://www.txdps.state.tx.us/RegulatoryServices/prescription_program/prescri
ptionforms.htm
o If either your DPS or DEA is expired you can’t prescribe controlled substances till
renewal is completed
o DPS
 Must be licensed by BON prior to applying for DPS
 Prior to registering for DPS your supervising/delegating physician must be listed
with the Texas Medical Board as giving you prescriptive authority for controlled
substances.
 For forms such as application or modification of registration:
http://www.dps.texas.gov/RSD/ControlledSubstances/csforms.htm
 Must update if change practice site and/or delegating physician. Complete and
submit Modification of Registration PA/APN form.
 Each physician delegating controlled substances must sign all forms and be
registered with TMB. This includes renewals.
o DEA
 Must have DPS prior to submitting application for DEA
 Inform DEA of change in status including name, address or schedules of APRN.
 DOES NOT require notification regarding change in delegating physician
 Application/renewal/change can be done online:
http://www.deadiversion.usdoj.gov/drugreg/index.html
 For changes go under registration tools, link “registration changes”
Drug Samples
o APRN may sign for and distribute samples if:
 Met all requirement to sign prescription drug orders (including having
delegation written in PAA or protocol)
 Samples are only for drugs APRN is eligible to prescribe
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Record of sample is maintained and samples are labeled as specified in
dangerous drug act or controlled substances act
o Must keep record of obtaining and distrusting samples. Must maintain record of names
of drugs and lot numbers for at least 2 years. Notation must be made in each patient’s
chart when a sample is distributed.
o Gold standard – keep log of all drugs distributed to include name of the patient, drug,
lot number and date given. This allows easy access to list of patients who received a
drug sample should that medication be recalled
o Drugs must be properly labeled to include patient’s name, instructions for taking the
medication including dosage, frequency and duration of treatment
NP and CNS Practice Issues
o Law prevents APRNs and PAs from participating in the care of other’s physician’s
patients without prior consent of those physicians. Usually, this prior consent is
accomplished by asking physicians to sign a statement acknowledging the physician
understands that APRNs assist in medical management and grants permission for any
APRN assigned to the hospital service to participate in the care of patients the physician
admits. Physicians routinely sign these statements when the physician applies or reapplies for privileges.
o APRNs educated in primary care may care for hospitalized patients that are stable and
not critically ill. These APRNs are not confined to ambulatory care settings by the BON.
 Recommended only APRNs educated in acute or critical care work in intensive
care settings
o APRNs may not certify (re-certify) a terminal illness but may act as attending
practitioner if hospice patient selects a NP to act in that capacity. Unfortunately federal
legislation that enabled the change to the CMS rules to allow this specified NPS and did
not include CNSs.
o APRNs may declare death (as can any RN) but only a physician can sign a death
certificate. May not declare death if resuscitation has been initiated or the patient is on
artificial life support
o Physicians may not jointly own a practice with an APRN
o In advertising their services to the public, APRNS must avoid any reference to
“medicine” or “medical practice”
o CNS role vs NP role
 Should CNS graduates seek APRN authorization from the BON?
 Some CNSs in the traditional role are not sure if should bother going
through the process of being authorized as CNS by BON. If the CNS
graduate does not obtain authorization to work in CNS role that nurse
cannot claim to be or use any title indicating that the nurse is a CNS
when working in a clinical role. This prohibition includes using national
certification titles that indicated advance practice status, such as ACNSBC even if certified by ANCC. The CNS would still be able to use masters
or doctoral degree as a credential.
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Not being recognized as CNS by BON may make it more difficult to find
job advertised for CNS
 The traditional CNS role focuses on improving nursing care for a population of
patients. Originally the role did not involve medical aspects of care and the CNS
improved nursing through assessment, consultation, research and teaching.
CNSs analyze systems to obtain optimal results. A growing percentage of CNSs
treat individual patients and have prescriptive authority and are educated to
diagnose, treat and prescribe for patients within their specialty. CNSs apply
their traditional skills to improve the medical aspects care they provide. CNS
education includes both acute and primary care settings
 NP role focuses on managing the treatment for individual patients within a
specific population of patients
 Role analysis of Psychiatric Mental Health NPs and CNSs and Gerontological
CNSs and NPs show they have identical functions and perform the same jobs
 There is an overlap in the role of the CNS and NP. This often creates confusion
in determining if the job requires a CNS or NP. NPs may be hired to meet some
patient care goals that are more commonly associated with the CNS role and
CNSs with prescriptive authority may be hired to manage medical aspects of
care for individual patients, a role more commonly assumed by NPs
 Typically an NP is hired if medical management is the major need of the
position and a CNS is hired if the employer needs an APRN who can
improve nursing care and bring a team of interdisciplinary providers
together to work as a team
Scope of Practice
 Physician scope is unlimited and their delegated authority is broad often
resulting the physician trying to delegate care that is beyond the APRN’s scope.
A physician can delegate any care they think an individual is competent to
perform. Physicians often fail to understand other practitioners must function
within the limits of their license. For example a women health NP who works
for family physician may only care for women and may not provide primary care
to children or men.
 An APRN is not able to accept a delegation that is outside his/her scope of
practice
 Diagnosing and prescribing are in the APRNs scope of practice (otherwise APRN
would not be able to accept the delegation) but in the State of Texas these acts
are not performed independently. Delegation must be thru a PAA or protocol.
 Other aspects of care most APRNs provide are typically considered as
nursing acts
 Expand scope to include new procedures/activities.
 BON posted guidelines for Determining Scope of Practice with FAQs
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This more of an issue than simply learning how to perform a particular
procedure. Patient selection criteria, underlying physiology and/or
pathophysiology, indications for and contraindications to the procedure
are among the many concepts that are fundamental to learning a new
procedure. Must learn to respond and manage adverse
reactions/complication that may occur. In many cases, on the job
training will not include this type of content. Need to be able to provide
evidence of education/training and documentation of competence
 APRN Delegating to Unlicensed Personnel
 Unlike a physician, an APRN’s ability to delegate to unlicensed personnel
is limited, it is the same as that of an RN
 BON Position statement 15.18 permits RNs and LVNs to take orders from
APRNs. Physician is not required to be physically present at the location where
APRN provides care. The order is not required to be countersigned by the
physician.
o APRN may order orthotics and prosthetics but need be delegated by physician in PAA or
protocol
o BON views ordering DME and medical supplies in the scope of practice of APRNs. The
difficulties are caused by reimbursement issues created by federal and state regulations.
ACA makes it clear that NP and CNSs may order DMEs but requires the physician to cosign documentation verifying the face-to-face evaluation occurred.
o Federal law currently states that only physician may order home health services
(regardless of payer). This is why home health agencies that are Medicare-certified
cannot accept orders or plan of care for home health from an APRN.
o APRNs may not order restraints for behavioral reasons. May do so for medical purposes
if permitted by facility bylawas
o Federal regulations are silent about whether or not APRNs can sign paper work or order
DNR status. It is within the APRN’s scope. Texas law specifies a physician must note the
patient’s wish not be resuscitated, consequently APRNs should not sign DNR orders or
“out of hospital DNR” form.
 May write verbal order for DNR at direction of an attending physician who
witnessed the patient’s statement
 APRN can complete the required documentation related to DNR order if the
APRN discussed the patient’s wished with pt/family. DNR orders need to be
accompanied by the following documentation:
 Persons whom APRN spoke and if not patient, why and relationship to
the patient
 Summary of the discussion
 Decision reached
Apply to be Medicare Provider (only need if going to bill Medicare for services)
o Novitas Solutions Website: www.novitas-solutions.com
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o Novitas is the Medicare Administrative Contractor for the region in which Texas resides
National Provider Identifier (NPI): https://nppes.cms.hhs.gov/NPPES/Welcome.do
Texas Board of Nursing. (2014). Board to issue advance practice registered nurses a second license
number. Texas Board of Nursing Bulletin, 45(1), 1.
Texas Board of Nursing. (2014). New and updated continuing nursing education requirements. Texas
Board of Nursing Bulletin, 45(2), 1.
Texas Administrative Code, Title 22, Part 9. Texas Medical Board, Board Rule. Chapter 193. Standing
Delegation Orders §193.1-193.20 (2013). https://www.tmb.state.tx.us/idl/45407D14-79CD-93CE-1A70192E86E93374
Texas Administrative Code, Title 22, Part 11. Texas Board of Nursing Advanced Practice Nurses. Chapter
221. Definitions. §221.1. §221.2, §221.8, §221.11, §221.12, §221.13
Texas Administrative Code, Title 22, Part 11. Texas Board of Nursing Advanced Practice Nurse. Chapter
222. Prescriptive Authority. §222.1-§222.10
Woolbert, L. F., & Ziegler, B. (2013). A guide for APRN practice in Texas (4th ed.). Austin, TX: Coalition for
Nurses in Advanced Practice and Texas Nurse Practitioners.
Woolbert, L.F. (May, 2013). Personal Conversation.
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