APN Practice and Prescriptive Authority

     Re: Content of Practice Protocols

Q: How do I know what type of protocols or practice guidelines are best for my practice?

A: The type and specificity of protocols, practice guidelines or practice agreements should be based upon six factors: 1) Texas law, 2) the specific medical aspects of care to be performed by the APN, 3) the experience and education of the APN, 4) the type of site and availability of medical consultation, 5) the input of the delegating physician, and 6) any federal regulations applicable to your practice site.

The law and consequently BNE and TMB rules allow a great deal of flexibility in the type of protocols, even those that include delegation of prescriptive authority. The rules require the protocols to be based upon the education and experience of the advanced practice nurse and the complexity of the problem to be treated. The rules of both agencies specifically state that protocols do not have to include specific steps that the APN must follow and should allow the APN to exercise professional judgment.

In general terms, the protocols should address the APN's scope of practice, the settings in which the protocol will be used and the physician's responsibility to supervise prescriptive authority and the physician's availability for consultation.

Under the definition of "protocols," Texas Medical Board (TMB) rules require protocols authorizing prescriptive authority to address what categories or types of drugs an APN may, or may not, prescribe. The rules also require statements identifying any limitations on the number of dosage units and refills permitted, and instructions to be given the patient for follow-up and monitoring. In rules affecting medically underserved sites, there is also a reference that protocols must identify if, and under what circumstances, the APN may permit the pharmacist to make generic substitutions. Based upon a provision in SB 1131, passed in 1999, protocols should also identify any licensed nursing personnel that may call prescriptions to the pharmacy for the APN.

CNAP has a Sample Practice Protocol with explanatory notes and forms available for purchase. Click the link to go to the CNAP Publications page. This sample meets the requirements for protocols required by state law. However, they will not meet all the requirements if the APN is practicing in a Rural Health Clinic.