Quick Facts for Physicians working with APRNs in State of Texas
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Must keep documents related to APRN at APRN practice site and retain records for 2 years after an
agreement is terminated
Physicians must register prescriptive authority delegation with TMB within 30 days and modify
registration within 30 days of any changes (includes changes in site address(s), termination, etc.)
Physicians may delegate
o Non-prescription drugs, DME, dangerous drugs
o Controlled substances limited to schedule III-V except may also delegate schedule II if:
 Facility-based and caring for pts in ER
 Facility-based and caring for inpatients with expected stay greater than 24hrs
 Caring for hospice patients in any setting
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:
 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
Authorizing Physician’s responsibilities
o Verify the APRN has valid APRN license and prescriptive authority authorization from TX BON,
valid DPS and DEA registration if delegating authority for controlled substances
o Participates in the development of PAA or if facility-based practice, a protocol. Physician must
determine what medical acts he/she will delegate. Sign and date document, ensure it is
updated as necessary but at minimum reviews, signs and dates it annually
o Must register the APRN’s name and license number with TMB. Physician should keep a record
of persons to whom the physician delegates prescriptive authority and dates of the delegation.
o Physician must meet all supervisory/quality assurance requirements established in PAA or
protocol
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 Delegating thru PAA:
 Delegate in conformance to what a reasonable and prudent physician would find
consistent with sound medical judgment based on the education and experience of
the APRN
 Meet monthly with APRN at time and place agreed upon by the physician and APRN
 Perform chart review (# and manor of chart review determined by physician and
APRN)
 Be available for consultation and referral
 Device and enforce a system to account for and monitor the prescriptions issued
under the physician’s delegation
 Maintain a copy of the PAA and documentation of compliance with quality assurance
requirements, and retain those records for 2 years from the date of terminating the
agreement
Physician APRN Quick Facts 1
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Delegating thru protocol:
 Delegate in conformance to what a reasonable and prudent physician would find
consistent with sound medical judgment based on the education and experience of
the APRN
 Device and enforce a system to account for and monitor the prescriptions issued
under the physician’s delegation
 Perform any quality assurance or supervision activities established by protocol and in
conformity to facility bylaws and policies
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
o May appoint one or more alternate physicians to assume quality assurance and consultation
duties when the delegating physician is out of town or otherwise unavailable
o Cooperate with the TMB and BON in any audit or investigation involving the delegation of
prescriptive authority
o Recommended to keep all documentation related to delegation (including agreements, quality
meetings, etc.) for 2 years after termination of delegation
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.
Physician is not held liable for the acts of APRN unless the physician had an active role in the patient’s
care. Texas law specifically states that a physician is not liable simply because he or she delegated
prescriptive authority unless the physician knows the APRN is not qualified
o §157.060, Occupations Code (Medical Practice Act) Physician Liability for Delegated Act :
Unless the physician has reason to believe the physician assistant or advanced practice
registered nurse lacked the competency to perform the act, a physician is not liable for an act
of a physician assistant or advanced practice registered nurse solely because the physician
signed a standing medical order, a standing delegation order, or another order or protocol
authorizing the physician assistant or advanced practice registered nurse to administer,
provide, carry out, or sign a prescription drug order.
o Not common but physician supervising APRN can be held liable for actions of APRN typically
for the following common reasons
 Inadequate supervision by the physician
 Failure to establish standardized policies and procedures for the APRN
 Over-delegation of duties by the supervising physician resulting in the APRN practicing
beyond his or her scope of practice
Statement from Carolyn Buppert, CRNP, JD: “physician collaborators are being dropped from
malpractice lawsuits against NPs when the physician testifies that the NP did not consult him or her
and when there is no evidence that the NP conferred with the physician about the case” (Woolbert, et
al., 2013, pg 107)
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References
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-1A70-192E86E93374
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.
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