81R4694 YDB-F
By: Orr H.B. No. 696
A BILL TO BE ENTITLED
AN ACT
relating to a physician's authority to delegate prescribing acts to
advanced practice nurses or physician assistants.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. The heading to Subchapter B, Chapter 157,
Occupations Code, is amended to read as follows:
SUBCHAPTER B. PRESCRIPTIVE AUTHORITY AGREEMENTS WITH [DELEGATION
TO] ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS
SECTION 2. Section 157.051, Occupations Code, is amended by
adding Subdivisions (2-c) and (4) to read as follows:
(2-c) "Medication order" has the meaning assigned by
Section 551.003.
(4) "Prescription drug order" means an order from a
physician or a physician's designated agent to a pharmacist for a
drug or device to be dispensed.
SECTION 3. Section 157.0511, Occupations Code, is amended
to read as follows:
Sec. 157.0511. PHYSICIAN AUTHORITY [PRESCRIPTION DRUG
ORDERS]. (a) In a prescriptive authority agreement executed
under Section 157.052, a physician may provide an advanced practice
nurse or physician assistant authority to prescribe or order a
dangerous drug or controlled substance, including authority to sign
a prescription drug order or medication order. [A physician's
authority to delegate the carrying out or signing of a prescription
drug order under this subchapter is limited to:
[(1) dangerous drugs; and
[(2) controlled substances to the extent provided by
Subsection (b).]
(b) [A physician may delegate the carrying out or signing of
a prescription drug order for a controlled substance only if:
[(1) the prescription is for a controlled substance
listed in Schedules III, IV, or V as established by the commissioner
of public health under Chapter 481, Health and Safety Code;
[(2) the prescription is for a period not to exceed 30
days;
[(3) with regard to the refill of a prescription, the
refill is authorized after consultation with the delegating
physician and the consultation is noted in the patient's chart; and
[(4) with regard to a prescription for a child less
than two years of age, the prescription is made after consultation
with the delegating physician and the consultation is noted in the
patient's chart.
[(b-1) The board shall adopt rules that require a physician
who delegates the carrying out or signing of a prescription drug
order under this subchapter to maintain records that show when and
to whom a delegation is made. The board may access the physician's
records under this subsection as necessary for an investigation.
[(c)] This subchapter does not modify the authority granted
by law for an advanced practice [a licensed registered] nurse or
physician assistant to administer or provide a medication,
including a controlled substance listed in Schedule II as
established by the commissioner of state [public] health services
under Chapter 481, Health and Safety Code, that is authorized by a
physician under a physician's order, standing medical order,
standing delegation order, or protocol.
SECTION 4. Section 157.052, Occupations Code, is amended to
read as follows:
Sec. 157.052. PRESCRIPTIVE AUTHORITY AGREEMENT
[PRESCRIBING AT SITES SERVING CERTAIN MEDICALLY UNDERSERVED
POPULATIONS]. (a) A physician may enter into a prescriptive
authority agreement with an advanced practice nurse or physician
assistant. The prescriptive authority agreement must:
(1) identify the physician's and the advanced practice
nurse's or physician assistant's areas of practice and any
specialties;
(2) describe any limitations on the advanced practice
nurse's or physician assistant's authority to prescribe or order
dangerous drugs, controlled substances, or medical devices in
accordance with Section 157.055;
(3) describe a prescriptive authority quality
evaluation and improvement plan and specify methods for documenting
the implementation of the plan; and
(4) specify a process to ensure collaboration between
the physician and the advanced practice nurse or physician
assistant.
(b) The physician and the advanced practice nurse or
physician assistant may specialize in different practice areas and
enter into a prescriptive authority agreement if the prescriptive
authority agreement demonstrates an appropriate link between the
specialty practice area of the physician and the specialty practice
area of the advanced practice nurse or physician assistant.
(c) The degree of collaboration between the physician and
the advanced practice nurse or physician assistant specified in the
prescriptive authority agreement may vary based on the advanced
practice nurse's or physician assistant's education, experience,
and skill in treating patients.
(d) Except as provided by Subsection (e), a physician may
enter into prescriptive authority agreements with not more than
eight advanced practice nurses and physician assistants or their
full-time equivalents, unless a reasonably prudent physician would
consider agreements with more than eight advanced practice nurses
and physician assistants to be safe based on:
(1) the advanced practice nurses' and physician
assistants' education, experience, knowledge, skills, and
abilities; and
(2) either:
(A) the type of patients served; or
(B) the extent to which access to care by a
medically underserved population is improved.
(e) The limitation on the number of prescriptive authority
agreements under Subsection (d) does not apply to an agreement at a
hospital licensed under Chapter 241, Health and Safety Code, or
owned or operated by this state, in which the physician and the
advanced practice nurses and physician assistants who are parties
to the agreement are authorized to practice.
(f) The board shall cooperate with the Texas Board of
Nursing in adopting rules under this subchapter to eliminate, to
the extent possible, conflicts between the rules adopted by each
board.
(g) This section shall be liberally construed to allow the
use of prescriptive authority agreements to safely and effectively
utilize the skills and services of advanced practice nurses and
physician assistants. [In this section:
[(1) "Health manpower shortage area" means:
[(A) an urban or rural area of this state that:
[(i) is not required to conform to the
geographic boundaries of a political subdivision but is a rational
area for the delivery of health service;
[(ii) the secretary of health and human
services determines has a health manpower shortage; and
[(iii) is not reasonably accessible to an
adequately served area;
[(B) a population group that the secretary of
health and human services determines has a health manpower
shortage; or
[(C) a public or nonprofit private medical
facility or other facility that the secretary of health and human
services determines has a health manpower shortage, as described by
42 U.S.C. Section 254e(a)(1).
[(2) "Medically underserved area" means:
[(A) an area in this state with a medically
underserved population;
[(B) an urban or rural area designated by the
secretary of health and human services as an area in this state with
a shortage of personal health services or a population group
designated by the secretary as having a shortage of those services,
as described by 42 U.S.C. Section 300e-1(7); or
[(C) an area defined as medically underserved by
rules adopted by the Texas Board of Health based on:
[(i) demographics specific to this state;
[(ii) geographic factors that affect access
to health care; and
[(iii) environmental health factors.
[(3) "Registered nurse" means a registered nurse
recognized by the Texas Board of Nursing as having the specialized
education and training required under Section 301.152.
[(4) "Site serving a medically underserved
population" means:
[(A) a site located in a medically underserved
area;
[(B) a site located in a health manpower shortage
area;
[(C) a clinic designated as a rural health clinic
under 42 U.S.C. Section 1395x(aa);
[(D) a public health clinic or a family planning
clinic under contract with the Texas Department of Human Services
or the Texas Department of Health;
[(E) a site located in an area in which the Texas
Department of Health determines there is an insufficient number of
physicians providing services to eligible clients of federal,
state, or locally funded health care programs; or
[(F) a site that the Texas Department of Health
determines serves a disproportionate number of clients eligible to
participate in federal, state, or locally funded health care
programs.
[(b) After making a determination under this section that a
site serves a medically underserved population, the Texas
Department of Health shall publish notice of its determination in
the Texas Register and provide an opportunity for public comment in
the manner provided for a proposed rule under Chapter 2001,
Government Code.
[(c) At a site serving a medically underserved population, a
physician licensed by the board may delegate to a registered nurse
or physician assistant acting under adequate physician supervision
the act of administering, providing, or carrying out or signing a
prescription drug order, as authorized by the physician through a
physician's order, a standing medical order, a standing delegation
order, or another order or protocol as defined by the board.
[(d) An advertisement for a site serving a medically
underserved population must include the name and business address
of the supervising physician for the site.
[(e) Physician supervision is adequate for the purposes of
this section if a delegating physician:
[(1) is responsible for the formulation or approval of
the physician's order, standing medical order, standing delegation
order, or other order or protocol, and periodically reviews the
order and the services provided patients under the order;
[(2) is on-site to provide medical direction and
consultation at least once every 10 business days during which the
advanced practice nurse or physician assistant is on-site providing
care;
[(3) receives a daily status report from the advanced
practice nurse or physician assistant on any problem or
complication encountered; and
[(4) is available through direct telecommunication
for consultation, patient referral, or assistance with a medical
emergency.]
SECTION 5. Section 157.055, Occupations Code, is amended to
read as follows:
Sec. 157.055. ORDERS AND PRESCRIPTIVE AUTHORITY AGREEMENTS
[PROTOCOLS]. (a) A prescriptive authority agreement [protocol]
or other order shall be defined in a manner that promotes the
exercise of professional judgment by the advanced practice nurse
and physician assistant commensurate with the education and
experience of that person. Under this section, a prescriptive
authority agreement or [an] order [or protocol] used by a
reasonable and prudent physician exercising sound medical judgment
[:
[(1)] is not required to:
(1) describe the exact steps that an advanced practice
nurse or a physician assistant must take with respect to each
specific condition, disease, or symptom; or [and]
(2) [may] state the specific drugs, medical devices,
or types or categories of drugs [medications] that may be
prescribed or the specific drugs, medical devices, or types or
categories of drugs [medications] that may not be prescribed.
(b) A prescriptive authority agreement is considered a
protocol for the purpose of fulfilling any requirement for a
protocol imposed under any other law.
SECTION 6. Section 157.056, Occupations Code, is amended to
read as follows:
Sec. 157.056. PRESCRIPTION INFORMATION. The following
information must be provided on each prescription subject to this
subchapter:
(1) the patient's name and address;
(2) the drug to be dispensed;
(3) directions to the patient regarding the taking of
the drug and the dosage;
(4) the intended use of the drug, if appropriate;
(5) the name, address, and telephone number of the
physician;
(6) the name, address, telephone number, and
identification number of the advanced practice [registered] nurse
or physician assistant [completing or] signing the prescription
drug order;
(7) the date; and
(8) the number of refills permitted.
SECTION 7. Section 157.057, Occupations Code, is amended to
read as follows:
Sec. 157.057. ADDITIONAL IMPLEMENTATION METHODS. The
board may adopt additional methods to implement:
(1) a physician's prescription; or
(2) the delegation of the signing of a prescription
under a physician's order, standing medical order, standing
delegation order, or other order [or protocol].
SECTION 8. Sections 157.059(d), (e), (f), (i), and (j),
Occupations Code, are amended to read as follows:
(d) The delegation of authority to administer or provide
controlled substances under Subsection (b) must be under a
physician's order, medical order, standing delegation order, or
prescriptive authority agreement [protocol] that requires adequate
and documented availability for access to medical care.
(e) The physician's orders, medical orders, standing
delegation orders, or prescriptive authority agreements
[protocols] must require the reporting of or monitoring of each
client's progress, including complications of pregnancy and
delivery and the administration and provision of controlled
substances by the nurse midwife or physician assistant to the
clients of the nurse midwife or physician assistant.
(f) The authority of a physician to delegate under this
section is limited to:
(1) eight [three] nurse midwives or physician
assistants or their full-time equivalents; and
(2) the designated facility at which the nurse midwife
or physician assistant provides care.
(i) This section authorizes a physician to delegate the act
of administering or providing a controlled substance to a nurse
midwife or physician assistant but does not require physician
delegation of:
(1) further acts to a nurse midwife; or
(2) the administration of medications by a physician
assistant or advanced practice [registered] nurse other than as
provided by this section.
(j) This section does not limit the authority of a physician
to delegate the [carrying out or] signing of a prescription drug
order involving a controlled substance under this subchapter.
SECTION 9. Section 157.060, Occupations Code, is amended to
read as follows:
Sec. 157.060. PHYSICIAN LIABILITY FOR DELEGATED ACT. Unless
the physician has reason to believe the physician assistant or
advanced practice nurse lacked the competency to perform the act, a
physician is not liable for an act of a physician assistant or
advanced practice nurse solely because the physician signed a
prescriptive authority agreement, a standing medical order, a
standing delegation order, or another order [or protocol]
authorizing the physician assistant or advanced practice nurse to
administer, provide, [carry out,] or sign a prescription drug
order.
SECTION 10. The following statutes are repealed:
(1) Section 157.051(2), Occupations Code;
(2) Section 157.053, Occupations Code;
(3) Section 157.054, Occupations Code;
(4) Section 157.0541, Occupations Code; and
(5) Section 157.0542, Occupations Code.
SECTION 11. The changes in law made by this Act apply only
to a delegation by a physician to an advanced practice nurse or
physician assistant under Subchapter B, Chapter 157, Occupations
Code, on or after the effective date of this Act.
SECTION 12. This Act takes effect September 1, 2009.