“Legal requirements for physicians who work with NPPs are often changing, and in some cases it’s an opaque area of a physician’s business.”
and critical care, take patient histories, perform physical examinations and well visits, order and interpret lab tests, pre- scribe drugs within state regulations, perform and assist in minor surgeries, provide patient education and counsel- ing, make referrals, and handle other responsibilities. PAs’ and APNs’ scope of practice in- cludes providing any medical service delegated by a physician that is consis- tent with the person’s training, educa- tion, and experience. Consult Section 204.202 of the Texas Occupations Code,
www.tmb.state.tx.us/rules/codes/chap ter204.php#204202, relating to scope of practice for PAs for more information. (Note: See the TMA website at www.tex
med.org/npp-article.aspx for direct links to this and the other online resources mentioned in this article.) APNs also provide a broad range of health services, the scope of which is based on the APN’s license, education, experience, and particular specialty area. APNs and PAs practice in various settings, including primary and alternative prac- tice sites, medically underserved regions, and facility-based practices. The Texas Board of Nursing, www
.bon.texas.gov, and the Nursing Practice Act,
www.bon.texas.gov/nursinglaw/ npa.html, do not specifically list acts
30 TEXAS MEDICINE March 2012
an APN may perform. The only guid- ance provided is that registered nurses (RNs) must exercise good professional judgment in accepting assignments and/ or performing procedures. The Nursing Practice Act says RNs, including APNs, may not engage in activities that require independent medical diagnosis. Without definitive guidance regarding what a reg- istered nurse may do, determining what an APN may and may not do is difficult. Mr. Rivera suggests physicians con-
sult the Texas Board of Nursing for infor- mation about the various specialty certi- fications for APNs. In addition, he says specialty professional societies for physi- cians and APNs can provide resources for scope-of-practice protocols, billing and documentation guidance, and supervi- sion and compliance requirements. Appropriate physician supervision of
NPPs must ensure NPPs don’t overstep their legal boundaries. Physician super- vision requirements for PAs and APNs are different. Delegation of prescriptive authority has supervision rules, which vary by practice site — medically under- served populations, primary sites, alter- nate sites, and facilities. For additional guidance, consult
TMB’s Site-Specific Prescriptive Del- egation Statute and Rule Chart online,
www.tmb.state.tx.us/professionals/np/
Site-SpecificPrescriptiveDelegationStat ueAndRule-2010-08-25.pdf. The chart includes links to the Texas Occupations Code and Texas Administrative Code for information on site-specific requirements for delegating physicians, chart reviews, site visits, supervision, and more. For instance, state law requires super- vising physicians to randomly review 10 percent of charts for NPPs who practice at alternate sites. NPPs can’t prescribe drugs classi- fied as C2 by the federal Controlled Substances Act. This category includes drugs such as morphine and hydromor- phone, which have prescriptions tracked by the Drug Enforcement Agency. NPPs can write prescriptions for controlled substances categorized as C3, such as Vicodin and codeine. TMA’s Nonphysician Providers: Hir- ing, Billing and Delegation of Duties for a Nonphysician Practitioner provides more information about physician supervision of NPPs.
NPP rules, regulations
Under the state’s Medical Practice Act, supervising physicians who delegate certain medical acts must make sure the person does not represent to the public that he or she has authorization to prac- tice medicine. Also, physicians should determine the medical act:
• Can be properly and safely performed by the person to whom the medical act is delegated;
• Is performed in its customary man- ner; and
• Is not in violation of any other statute.
The law adds that the delegating phy- sician is “responsible for the medical acts of the person performing the delegated medical acts.” To access the statute, visit
www.statutes.legis.state.tx.us/docs/OC/ htm/
OC.157.htm. Texas Medical Board (TMB) Executive
Director Mari Robinson, JD, says viola- tions of physician oversight of PAs and APNs vary in severity. Physicians who wish to delegate prescriptive author- ity to PAs and APNs must register on the TMB website,
www.tmb.state.tx.us/ professionals/physicians/delegatingPre
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