Posted July 17, 2002
By Jerri Lynn Ward, J.D., Garlo Ward, P.C.
Recent amendments to rules 222.1-222.10 of the TAC clarify the definition of professional nursing and the duties of Advanced Practice Nurses.
Advanced practice nurses with limited prescriptive authority can:
- sign prescription drug orders in alternate sites where the physician has delegated the authority to do so, and
- sign prescription drug orders in sites where the Texas State Board of Medical Examiners has granted a waiver or modification of site or supervisory requirements to the delegating physician.
Eligibility for Limited Prescriptive Authority
To be approved by the board to carry out or sign prescription drug orders and issued a prescription authorization number, a Registered Nurse (RN) must:
- have permanent or provisional authorization by the board to practice as an advanced practice nurse. RNs with Interim Authorization to practice as advanced practice nurses are not eligible for a prescription authorization number;
- file a complete application for Limited Prescriptive Authority and submit such evidence as required by the board to verify the following educational qualifications
To be eligible for Limited Prescriptive Authority, advanced practice nurses must have successfully completed courses in
- pharmacotherapeutics,
- pathophysiology, and
- advanced assessment, diagnosis and management of problems within the clinical specialty.
Nurse Practitioners, Nurse-Midwives and Nurse Anesthetists will be considered to have met the course requirements of this section on the basis of courses completed in the advanced educational program.
Requirements for Clinical Nurse Specialists
To obtain Limited Prescriptive Authority, Clinical Nurse Specialists:
- shall submit documentation of successful completion of separate courses in the content areas of pharmacotherapeutics, pathophysiology, and advanced assessment, diagnosis and management of problems within the clinical specialty
- shall complete these academic courses at a regionally accredited institution with a minimum of 45 clock hours per course.
The board, by policy, may determine that certain specialties of Clinical Nurse Specialists meet one or more of the course requirements on the basis of the advanced educational program.
Disqualifications for Eligibility
Clinical Nurse Specialists who have been approved by the board as advanced practice nurses by petition on the basis of completion of a non-nursing master’s degree shall not be eligible for prescriptive authority.
Use of Limited Prescriptive Authority
Advanced Practice Nurses may use their prescribing privileges at eligible sites, including:
- sites serving certain medically underserved populations,
- the physician’s primary practice sites, alternate sites, and facility-based practice sites.
Exceptions Granted by the Texas State Board of Medical Examiners
The requirements for utilizing limited prescriptive authority may be modified or waived if a delegating physician has received a modification or waiver from the Texas State Board of Medical Examiners.
Authority of Advanced Practice Nurses
Advanced practice nurses with limited prescriptive authority may:
- sign prescription drug orders in alternate sites where the physician has delegated the authority to do so. An alternate site is a practice site within 60 miles of the delegating physician’s primary practice site where services similar to the services provided at the delegating physician’s primary practice site are provided; and
- sign prescription drug orders in sites where the Texas State Board of Medical Examiners has granted a waiver or modification of site or supervisory requirements to the delegating physician.
Renewal of Limited Prescriptive Authority
The advanced practice nurse may renew the privilege to carry out or sign prescription drug orders along with the RN license renewal application.
To be eligible for renewal, the advanced practice nurse must:
- Submit forms to the board showing completion of at least five contact hours of continuing education in pharmacotherapeutics within the last two years in addition to other continuing education requirements.
Minimum Standards for Carrying Out or Signing Prescriptions
Advanced practice nurses with a valid prescription authorization number can carry out or sign prescription drug orders for only those drugs that are:
- classified as dangerous drugs;
- authorized by Protocols or other written authorization for medical aspects of patient care; and
- prescribed for patient populations within the accepted scope of professional practice for the advanced practice nurse’s specialty area.
Advanced practices nurses cannot authorize or issue prescriptions for controlled substances.
Advanced practice nurses must comply with the requirements for adequate physician supervision published in the rules of the Board of Medical Examiners relating to Delegation of the Carrying Out or Signing of Prescription Drug Orders to Physician Assistants and Advanced Practice Nurses as well as other applicable laws.
A protocol or other written authorization:
- is not required to 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 medications that may be prescribed or contain the types or categories of medications that may not be prescribed.
- shall be written, agreed upon and signed by the advanced practice nurse and the physician
- will be reviewed and signed at least annually, and
- maintained in the practice setting of the advanced practice nurse.
Prescribing at Sites Serving Certain Medically Underserved Populations
When carrying out or signing prescription drug orders at a site serving a medically underserved population, the advanced practice nurse shall”
- maintain Protocols or other written authorization that must be reviewed and signed by both the advanced practice nurse and the delegating physician at least annually;
- have access to the delegating physician or alternate delegating physician for consultation, assistance with medical emergencies, or patient referral;
- provide a daily status report to the physician on any problems or complications encountered that are not covered by protocol; and
- shall be available during on-site visits by the physician which shall occur at least every 10 business days that the advanced practice nurse is on site providing care.
Prescribing at Physicians’ Primary Practice Sites
When carrying out or signing prescription drug orders at a physician’s primary practice site, the advanced practice nurse shall:
- maintain Protocols or other written authorization that must be reviewed and signed by both the advanced practice nurse and the delegating physician at least annually;
- sign or co-sign prescription drug orders only for those patients with whom the physician has established or will establish a physician-patient relationship although the physician is not required to see the patient within a specified time period.
Prescribing at Alternate Sites
When carrying out or signing prescription drug orders at an alternate site, the advanced practice nurse shall:
- maintain Protocols or other written authorization that must be reviewed and signed by both the advanced practice nurse and the delegating physician at least annually;
- be on-site with the physician at least twenty percent of the time; and
- have access to the physician through direct telecommunication for consultation, patient referral, or assistance with a medical emergency;
Prescribing at Facility-based Practice Sites
When carrying out or signing prescription drug orders at a facility-based practice site, the advanced practice nurse shall:
- maintain Protocols or other written authorization developed in accordance with facility medical staff policies and reviewing the authorizing documents with the appropriate medical staff at least annually;
- sign or co-sign prescription drug orders in the facility in which the delegating physician is the medical director, the chief of medical staff, the chair of the credentialing committee, or a department chair; or a physician who consents to the request of the medical director or chief of the medical staff to delegate; and
- sign or co-sign prescription drug orders for the care or treatment of only those patients for whom physicians have given their prior consent.
Conditions for Obtaining and Distributing Drug Samples
The advanced practice nurse with a valid prescription authorization number may request, receive, possess and distribute prescription drug samples provided:
- all requirements for the advanced practice nurse to sign prescription drug orders are met;
- Protocols or other physician orders authorize the advanced practice nurse to sign the prescription drug orders;
- the samples are dangerous drugs only; and
- a record of the sample is maintained and samples are labeled as specified in the Dangerous Drug Act (Health and Safety Code, Chapter 483).
Enforcement
Any nurse who violates these rules shall be subject to removal of the authority to prescribe under this rule and disciplinary action by the board under Texas Occupations Code ยง301.452. The practice of the advanced practice nurse approved by the board to carry out or sign prescription drug orders is subject to monitoring by the board on a periodic basis.
The changes went into effect March 6, 2002.
All information in this article is informational only and is not legal advice. Should you have any questions or a situation requiring advice, please contact an attorney.
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Austin, Texas 78752-3714 USA
Telephone: 512-302-1103
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