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An Overview of APN Prescriptive Privileges in Texas
There are two primary limitations on prescriptive authority for APNs in Texas. Prescriptive authority must be 1) delegated by a physician, and 2) physicians can only delegate prescriptive authority at certain types of practice sites.
Sites that Qualify for Delegation of Prescriptive Authority
There are four designations for sites where physicians may delegate prescriptive authority to APNs or PAs.
1) Medically underserved
2) Facility-based practice
3) Physician’s primary practice
4) Alternate practice
In all these sites there are certain core supervision and documentation requirements.
The APN and delegating physician must:
1) develop protocols;
2) maintain a quality assurance process; and
3) keep a log of dates an alternate physician assumes supervision in place of the delegating physician.
4) In addition, the physician must be available when off-site for consultation, referral and assistance with emergencies.
5) 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).
6) 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 has one unifying concept. 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.
A physician delegating prescriptive authority in a primary practice site may only delegate to a total of three APNs or PAs or their full-time equivalents (FTEs). 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 one alternate site where the physician spends 20% of the time. The physician is limited to delegating prescriptive authority to no more than 3 APNs and/or PAs at a primary practice and alternate sites. The Alternate Site must be within 60 miles of the primary practice and is limiting to offering the same type of health care services as in the primary site. The physician 20% on-site time must be when the APN is also on site. The physician must review 10% of charts and be available as needed by phone.
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 three APNs and PAs (FTEs).
Options in Long-Term Care Facilities. APNs seeing patients in long-term care facilities have two options as 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 fewest paperwork and supervisory requirements.
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