Q: I know an NP who practices in a nursing facility in Texas. She writes telephone orders, but is not calling the physician for each medical order she writes. She just has the physician co-sign all her orders later. She thinks she does not need a protocol because she does not have prescriptive authority. However, she is managing medical aspects of care. Doesn’t she need a protocol AND prescriptive authority?
A:Yes, she needs protocols to manage medical aspects of care. If she is writing orders for medications, she also needs prescriptive authority.
I refer your colleague to the Board of Nurse Examiners’ Rules and Regulations on advanced practice nurses, § 221, and prescriptive authority for advanced practice nurses, § 222. The rules are available on the BNE Web Site. To find the rules, click "Nursing Practice Act and Rules and Regulations" on the home page. Then click either "web view" or "download document" under the "Rules and Regulations" heading. You can then click on the rule or subsection of the rule you would like to review.
Protocols are required when an NP performs medical aspects of care. If an NP is not actually taking a verbal or telephone orders from a physician, it is inappropriate to use this as a method to document the source of authority for this order. Some NPs and physicians avoid writing protocols because they think they have to be very specific. However, this is not the case. “Protocols” in §221.1 (12) is defined as
Written authorization to provide medical aspects of patient care which are agreed upon and signed by the advanced practice nurse and the physician, reviewed and signed at least annually, and maintained in the practice setting of the advanced practice nurse. Protocols or other written authorization shall promote the exercise of professional judgment by the advanced practice nurse commensurate with his/her education and experience. Such protocols or other written authorization need not describe the exact steps that the advanced practice nurse must take with respect to each specific condition, disease, or symptom and may state types or categories of drugs which may be prescribed rather than just list specific drugs.
Many APNs are uncertain about what constitutes “medical aspects of care.” In general, when the NP crosses the line from assessment, health counseling, and recommending over-the-counter medications to medical diagnosis and prescribing legend medications, then the NP is performing medical aspects of care. Assessment includes such functions as taking a history, performing a physical examination, and ordering and interpreting lab tests or x-rays. The NP performs these functions independently. On the other hand, making a diagnosis from the ICD-9 Manual or ordering drugs that can only be dispensed with a prescription require delegated authority from a physician. Even though medical diagnosis and treatment is part of your scope of practice as an NP, it is still considered medical practice in the state of Texas, and therefore requires protocols.
Prescriptive authority in nursing facilities is confusing for many people. Prescriptive authority is required when the drug order or prescription will be filled by an outpatient pharmacy. An NP does not need to have prescriptive authority to write orders in the hospital because that order is filled by an inpatient pharmacy. In nursing and long-term care facilities, however, orders for medications are all filled by a pharmacy outside the facility. Therefore, writing a medication order in a long-term care facility is just like writing a prescription.
In summary, your colleague certainly needs prescriptive authority to write orders for legend drugs in a nursing facility, and she cannot write an order for a controlled substance without a specific telephone or verbal order from the physician. In addition, if she is diagnosing and making treatment decisions (based on a medical diagnosis rather than a nursing diagnosis), she needs to write the parameters of her practice in a set of protocols. She and her collaborating physician must review, update, and sign the protocols once a year (or more frequently if needed), and a copy of the protocols should be available in each site the NP practices.
If your colleague needs a good resource for protocols, I suggest she purchase a copy of the Sample Practice Protocol with Explanatory Notes from the Coalition for Nurses in Advanced Practice.
While writing protocols and gaining prescriptive authority may take more time and thought now, I think your colleague will find this saves time in the long run. Having a physician approve and sign all orders wastes time for both the NP and physician and is totally unnecessary if proper mechanisms are in place. Most importantly, with protocols and prescriptive authority, she and her collaborating physician will be complying with current laws and regulations.
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