Delegated Prescriptive Authority

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Introduction

In the state of Texas, physicians are allowed

to delegate the signing of prescriptions for

medications to physician assistants and

advance nurse practitioners as set forth in

the Texas Occupations Code §§ 157.051 –

157.060 and the Texas Medical Board

(“TMB”) Rules, Title 22 of the Texas

Administrative Code, Chapter 193.6. In

addition, the Texas Board of Nursing

(“BON”) has specific additional regulations

that apply to advanced nurse practitioners

who have prescriptive authority. Finally, the

Texas State Board of Pharmacy (“SBOP”)

has rules that dictate, among other things,

what information must be included in

prescription orders. The rules and

regulations are somewhat long, and at times,

confusing and duplicative. The purpose of

this article is to summarize only key

portions of those laws and regulations.

Overview of “Delegation”

A physician should delegate prescriptive

authority pursuant to protocols that have

been agreed upon by the physician and the

physician assistant or advanced nurse

practitioner. Such protocols typically

authorize the physician assistant or

advanced nurse practitioner to diagnose and

treat a patient’s condition. The physician

may delegate prescriptive authority to

physician assistants and advanced nurse

practitioners for the carrying out and

prescribing of dangerous drugs and

controlled substances in Schedules III –V.

May 2011

The TMB rules use the word “delegation”

for a reason; neither the law nor the rules

allow anyone but the physician to exercise

independent medical judgment. The

physician remains responsible to his or her

patients for acts performed by others under

the physician’s delegated authority.

Certainly, physician assistants and advanced

nurse practitioners still remain

professionally responsible for the acts they

perform under the scope and authority of

their own licenses.

Physicians are allowed to delegate

prescriptive authority at various sites,

specifically, at medically underserved sites,

their primary practice or alternative practice

sites or at facility-based sites such as

hospitals. The rules vary depending upon the

site of practice, and all physicians, physician

assistants and advanced nurse practitioners

are encouraged to review the applicable

regulations.

At all times, a physician must use sound

medical judgment and should only delegate

the carrying out and signing of prescriptions

in those situations in which a reasonable and

prudent physician would delegate. The

physician should take into consideration the

training, competence and expertise of the

physician assistant or advanced nurse

practitioner before agreeing to the

delegation. The physician must provide

continuous supervision, but the constant

presence of the physician is not required.

Again, the TMB rules describe “adequate

supervision” which vary depending upon the

site.

Contents of the Prescription

Chapter 483 of the Texas Health and Safety

Code sets forth the law for prescribing

dangerous drugs. A “dangerous drug” is

defined as a device or drug that is unsafe for

self-medication, requires a prescription and

is not included in Schedules I through V.

“Controlled substances” are those

substances, including drugs, listed in

Schedules I through V and are governed by

Chapter 481 of the Texas Health and Safety

Code.

Chapters 481, 483 and 22 TAC §291.34 of

the Texas SBOP rules outline the required

contents of an original written, electronic or

faxed prescription. When a physician writes

a prescription for either a dangerous drug or

a controlled substance, it must contain the

following information: (a) date of issue, (b)

name and address of patient, (c) name and

quantity of the drug/controlled substance

prescribed (including refills, if applicable),

and, for controlled substances, quantity

listed numerically followed by the number

written as a word, (d) directions for use, (e)

intended use unless the physician determines

that furnishing that information would not

be in the best interest of the patient, (f)

name, address and telephone number of the

physician at the physician’s usual place of

business, legibly printed or stamped, and for

controlled substances, the physician’s

federal Drug Enforcement Administration

(“DEA”) registration number and the

physician’s Texas Department of Public

Safety (“DPS”) number. All prescriptions

(except those verbally transmitted) must be

manually or electronically signed by the

practitioner. Signature stamps are not

allowed. All Schedule II controlled

substance prescriptions must be written on a

DPS Official Prescription form available

only from the DPS.

Physicians are allowed to give verbal

prescription orders to a pharmacist or a

pharmacist intern under the direction of a

pharmacist through a designated agent. The

physician must designate in writing the

name of each person authorized to verbally

or electronically submit prescriptions,

maintain that list at the physician’s usual

place of business and provide the pharmacist

with that list upon request.

When a physician assistant or an advanced

nurse practitioner writes a prescription for

either a dangerous drug or a controlled

substance, the same information outlined

above, pertinent to the physician assistant or

the advance nurse practitioner, must be

included in the prescription as well as the

following additional information:

For physician assistants and advanced nurse

practitioners, the name, address and

telephone number of the delegating

physician must also be included, and when

writing a prescription for a controlled

substance, the Texas SBOP rules require

that the delegating physician’s DEA number

must ALSO be included. (The Texas BON

rules also require that the delegating

physician’s DEA number be included

whenever an advanced nurse practitioner

writes a prescription for a controlled

substance.) Of course, physician assistants

and advanced nurse practitioners must

include their own DPS and DEA numbers

when prescribing Schedule III-V controlled

substances.

Advanced nurse practitioners must first

apply for Prescriptive Authority with the

Texas BON and obtain a prescription

authorization number. The prescription

authorization number must also be included

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in any prescription written by the advanced

practice nurse. The BON Rules contain a

chapter that is specific to prescriptive

authority that all advanced nurse

practitioners are encouraged to be familiar

with. (See, Texas BON Rule, 22 TAC

222.1)

(NOTE: Texas House Bill 708 would grant

advanced nurse practitioners more

independence in certain activities including

prescribing. The HQRM department will

monitor this Bill as it makes its way through

the legislative process.)

Registering for Delegated Prescriptive

Authority

As of January 31, 2010, physicians,

physician assistants and advanced nurse

practitioners are required to complete the

supervision and prescriptive delegation

registration process online with the Texas

Medical Board at www.tmb.state.tx.us. It is

recommended that the nurse

practitioner/physician assistant complete the

process first since the physician is required

to attest last in order to complete the

relationship.

The Texas SBOP regulations require that a

physician keep a written list at his/her usual

place of business of each physician assistant

and advanced nurse practitioner authorized

to carry out or sign a prescription drug

order. At the request of a pharmacist, the

physician must furnish evidence of such

authorization for any specified physician

assistant or advanced nurse practitioner.

Summary

The laws and rules governing the delegation

of prescriptive authority are outlined in

various statutes and regulations and can be

difficult to navigate. Physicians, physician

assistants and advanced nurse practitioners

are encouraged to contact the HQRM

department for clarification and guidance.

A Word about Self-Prescribing and

Prescribing for Family Members….

The TMB does not prohibit a physician or

physician assistant from self-prescribing or

prescribing medications for friend or family

member, but the rules do outline the steps

that must be taken in these circumstances.

Except in very limited circumstances, when

prescribing any drug to a family member or

a person with whom the physician has a

close personal relationship, the physician

must maintain a medical record that includes

documentation of an adequate medical

history, and a history and physical. When

prescribing controlled substances, there

must be evidence of immediate need which

the TMB defines as “no more than 72

hours.” Although the rules are a bit

nebulous, it is recommended that the amount

of controlled substances that is prescribed in

these situations not exceed a 72 hour supply.

It is recommended that the physician

maintain some type of record on

himself/herself with similar information if

self-prescribing as awkward as that might

sound.

It is important to note that the American

Medical Association’s Opinion 8.19 – “Self-

Treatment or Treatment of Immediate

Family Members” states that physicians

should generally not treat themselves or

their immediate family members. The

Opinion points out that professional

objectivity may be compromised and affect

medical decision-making in these

circumstances and encourages physicians to

restrict such treatment to emergencies or

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when in an isolated setting where another

qualified physician is not readily available.

UNT Health submitted data on several

providers for the Diabetes Mellitus and

Preventive Care Measures Groups.

The Texas BON issued a Position Statement

in 2003, which was reviewed in 2011,

stating that advanced nurse practitioners

“should not provide medical treatment or

prescribe medications for themselves or any

individual with whom they have a close

personal relationship.” (See Position

Statement, 15.22) Although Position

Statements are not BON rules and do not

have the force of law, they do provide

guidance and alert nurses to issues that

cause concern to the BON about nursing

practices that may cause danger to the

public.

The HQRM department, under the direction

of the Chief Medical Officer, is currently

evaluating the PQRS measures for which

UNT Health will be submitting data for

2011.

Our submission is an exciting success for

UNT Health as we move forward to meet

increasing quality reporting requirements

established by CMS and other regulatory

agencies. The HQRM department looks

forward to working with providers in 2011

in this important quality initiative.

If you have any questions about PQRI/S

reporting, please contact Jan Stanton, RN,

Clinical Quality Coordinator, at

817.735.0228.

In general, self-prescribing and prescribing

for family members or close friends should

be avoided by all providers in every day

practice. Please contact the HQRM

department if you have any questions.

PQRI Update

The HQRM department is pleased to

announce that UNT Health submitted its

first Patient Quality Reporting Initiative

(“PQRI”) report for 2010. PQRI (now

known as the Physician Quality Reporting

System, or “PQRS”) is currently a voluntary

program established by the Centers for

Medicare and Medicaid Services (“CMS”)

for reporting data on quality measures.

Successful submission of data allows

participating providers to receive incentive

payments from CMS for services provided

to Medicare beneficiaries.

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Fax: 817-735-0271

817

735

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