APN Practice and Prescriptive Authority
      
     Re: Physician Supervision - Frequently Asked Questions

Q: Do APNs in Texas have to be supervised by a physician for all the services they perform?

A.  No. Except for prescribing medications and certain medical aspects of care, APNs do not require physician supervision for activities within their scopes of practice.

For most activities within the APN's normal scope of practice, the APN works under his or her own nursing license and is solely responsible for the quality of that care. Many health care services may be performed without physician involvement. For instance, when a certified nurse midwife attends a mother during a normal vaginal delivery or a nurse practitioner performs a physical exam, these activities require no physician involvement. If the physical exam reveals an abnormality and further assessment is required, the NP may independently order appropriate lab tests or x-rays. However, in order for the NP to go beyond this point in the assessment process, Texas law requires physician delegation through a practice agreement, practice guidelines or protocols.

Determining a diagnosis and treatment plan and prescribing medications are within the NP's and CNM's normal scope of practice as defined by their professional organizations. However, Texas law is more restrictive. It requires the APN to perform these functions with varying degrees of physician involvement. Diagnosis and treatment, not involving prescription medications, only requires a very general delegation statement from the physician, and an agreement from the physician to be available for consultation on any aspects of diagnosis and treatment that require consultation. This is usually referred to as a practice agreement (but the legal term is still protocols). If the patient requires a prescription for a medication, the authority to prescribe that medication requires additional physician delegation. The Texas State Board of Medical Examiners (TSBME) requires the physician to perform specific supervisory functions in a site serving a medically underserved population if the physician is not on site the majority of the time. You can find these requirements by referring to the Texas Administrative Code, Title 22, Chapter 193, Section 193.6 (b) through (h). The rules regarding physician supervision in primary practice sites and facility-based practice are more vague. In those situations the physician supervision must "conform to what a reasonable, prudent physician would find consistent with sound medical judgment but may vary with the education and experience of the APN."