§ 157.051. DEFINITIONS. In this subchapter:
(1) "Advanced practice nurse" has the meaning assigned
to that term by Section 301.152. The term includes an advanced
nurse practitioner.
(2) "Carrying out or signing a prescription drug
order" means completing a prescription drug order presigned by the
delegating physician, or the signing of a prescription by a
registered nurse or physician assistant.
(2-a) "Controlled substance" has the meaning assigned
to that term by Section 481.002, Health and Safety Code.
(2-b) "Dangerous drug" has the meaning assigned to
that term by Section 483.001, Health and Safety Code.
(3) "Physician assistant" means a person who holds a
license issued under Chapter 204.
Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999. Amended
by Acts 2003, 78th Leg., ch. 88, § 1, eff. May 20, 2003; Acts
2005, 79th Leg., ch. 269, § 1.27, eff. Sept. 1, 2005.
§ 157.0511. PRESCRIPTION DRUG ORDERS. (a) 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 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 public health 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.
Added by Acts 2003, 78th Leg., ch. 88, § 2, eff. May 20, 2003.
Amended by Acts 2005, 79th Leg., ch. 269, § 1.28, eff. Sept. 1,
2005.
§ 157.052. PRESCRIBING AT SITES SERVING CERTAIN MEDICALLY
UNDERSERVED POPULATIONS. (a) 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 Board of Nurse Examiners 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.
Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999. Amended
by Acts 2003, 78th Leg., ch. 88, § 3, eff. May 20, 2003.
§ 157.053. PRESCRIBING AT PHYSICIAN PRIMARY PRACTICE
SITES. (a) In this section, "primary practice site" means:
(1) the practice location of a physician at which the
physician spends the majority of the physician's time;
(2) a licensed hospital, a licensed long-term care
facility, or a licensed adult care center where both the physician
and the physician assistant or advanced practice nurse are
authorized to practice;
(3) a clinic operated by or for the benefit of a public
school district to provide care to the students of that district and
the siblings of those students, if consent to treatment at that
clinic is obtained in a manner that complies with Chapter 32, Family
Code;
(4) the residence of an established patient; or
(5) another location at which the physician is
physically present with the physician assistant or advanced
practice nurse.
(b) At a physician's primary practice site, a physician
licensed by the board may delegate to a physician assistant or an
advanced practice nurse acting under adequate physician
supervision the act of administering, providing, or carrying out or
signing a prescription drug order as authorized through a
physician's order, a standing medical order, a standing delegation
order, or another order or protocol as defined by the board.
(c) Physician supervision of the carrying out and signing of
prescription drug orders 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 particular advanced
practice nurse or physician assistant. A physician shall provide
continuous supervision, but the constant physical presence of the
physician is not required.
(d) An alternate physician may provide appropriate
supervision on a temporary basis as defined and established by
board rule.
(e) A physician's authority to delegate the carrying out or
signing of a prescription drug order is limited to:
(1) three physician assistants or advanced practice
nurses or their full-time equivalents practicing at the physician's
primary practice site or at an alternate practice site under
Section 157.0541; and
(2) the patients with whom the physician has
established or will establish a physician-patient relationship.
(f) For purposes of Subsection (e)(2), the physician is not
required to see the patient within a specific period.
Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999. Amended
by Acts 2001, 77th Leg., ch. 112, § 1, eff. May 11, 2001; Acts
2003, 78th Leg., ch. 88, § 4, eff. May 20, 2003.
§ 157.054. PRESCRIBING AT FACILITY-BASED PRACTICE
SITES. (a) A physician licensed by the board may delegate, to one
or more physician assistants or advanced practice nurses acting
under adequate physician supervision whose practice is
facility-based at a licensed hospital or licensed long-term care
facility, the administration or provision of a drug and the
carrying out or signing of a prescription drug order if the
physician is:
(1) the medical director or chief of medical staff of
the facility in which the physician assistant or advanced practice
nurse practices;
(2) the chair of the facility's credentialing
committee;
(3) a department chair of a facility department in
which the physician assistant or advanced practice nurse practices;
or
(4) a physician who consents to the request of the
medical director or chief of medical staff to delegate the carrying
out or signing of a prescription drug order at the facility in which
the physician assistant or advanced practice nurse practices.
(b) A physician's authority to delegate under Subsection
(a) is limited as follows:
(1) the delegation must be made under a physician's
order, standing medical order, standing delegation order, or
another order or protocol developed in accordance with policies
approved by the facility's medical staff or a committee of the
facility's medical staff as provided by the facility bylaws;
(2) the delegation must occur in the facility in which
the physician is the medical director, the chief of medical staff,
the chair of the credentialing committee, or a department chair;
(3) the delegation may not permit the carrying out or
signing of prescription drug orders for the care or treatment of the
patients of any other physician without the prior consent of that
physician;
(4) delegation in a long-term care facility must be by
the medical director and is limited to the carrying out and signing
of prescription drug orders to not more than three advanced
practice nurses or physician assistants or their full-time
equivalents; and
(5) a physician may not delegate at more than one
licensed hospital or more than two long-term care facilities unless
approved by the board.
(c) Physician supervision of the carrying out and signing of
prescription drug orders 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 particular advanced
practice nurse or physician assistant. A physician shall provide
continuous supervision, but the constant physical presence of the
physician is not required.
(d) An alternate physician may provide appropriate
supervision on a temporary basis as defined and established by
board rule.
Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999. Amended
by Acts 2003, 78th Leg., ch. 88, § 5, eff. May 20, 2003.
§ 157.0541. PRESCRIBING AT ALTERNATE SITES. (a) In this
section, "alternate site" means a practice site:
(1) where services similar to the services provided at
the delegating physician's primary practice site are provided; and
(2) located within 60 miles of the delegating
physician's primary practice site.
(b) At an alternate site, a physician licensed by the board
may delegate to an advanced practice 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 through a physician's order, a standing
medical order, a standing delegation order, or another order or
protocol as defined by the board.
(c) Physician supervision is adequate for the purposes of
this section if the delegating physician:
(1) is on-site with the advanced practice nurse or
physician assistant at least 20 percent of the time;
(2) reviews at least 10 percent of the medical charts
at the site; and
(3) is available through direct telecommunication for
consultation, patient referral, or assistance with a medical
emergency.
(d) An alternate physician may provide appropriate
supervision to an advanced practice nurse or physician assistant
under this section on a temporary basis as provided by board rule.
(e) The combined number of advanced practice nurses and
physician assistants to whom a physician may delegate under this
section and at a primary practice site under Section 157.053 may not
exceed three physician assistants or advanced practice nurses or
the full-time equivalent of three physician assistants or advanced
practice nurses.
Added by Acts 2001, 77th Leg., ch. 112, § 2, eff. May 11, 2001.
Amended by Acts 2003, 78th Leg., ch. 88, § 6, eff. May 20, 2003.
§ 157.0542. BOARD WAIVER OF DELEGATION REQUIREMENTS. (a)
On determining that the conditions of Subsection (b) have been met,
the board may waive or modify any of the site or supervision
requirements for a physician to delegate the carrying out or
signing of prescription drug orders to an advanced practice nurse
or physician assistant under Sections 157.052, 157.053, 157.054,
and 157.0541, or under board rules. The board may not waive the
limitation on the number of primary or alternate practice sites at
which a physician may delegate the carrying out or signing of
prescription drug orders or the number of advanced practice nurses
or physician assistants to whom a physician may delegate the
carrying out or signing of prescription drug orders.
(b) The board may grant a waiver under Subsection (a) if the
board determines that:
(1) the practice site where the physician is seeking
to delegate prescriptive authority is unable to meet the
requirements of this chapter or board rules or compliance would
cause an undue burden without a corresponding benefit to patient
care;
(2) safeguards exist for patient care and for
fostering a collaborative practice between the physician and the
advanced practice nurses and physician assistants; and
(3) if the requirement for which the waiver is sought
is the amount of time the physician is on-site, the frequency and
duration of time the physician is on-site when the advanced
practice nurse or physician assistant is present is sufficient for
collaboration to occur, taking into consideration the other ways
the physician collaborates with the advanced practice nurse or
physician assistant, including at other sites.
(c) The board shall establish procedures for granting
waivers under this section. At a minimum, the procedures must
include a process for providing, if the board denies a waiver, a
written explanation for the denial and identifying modifications
that would make the waiver acceptable and a process for revoking,
suspending, or modifying a waiver previously granted. The process
for revoking, suspending, or modifying a waiver must include notice
and an opportunity for a hearing. The board may probate an order to
revoke, suspend, or modify a waiver.
(d) to (h) Repealed by Acts 2005, 79th Leg., ch. 269, §
1.49(2).
Added by Acts 2001, 77th Leg., ch. 112, § 2, eff. May 11, 2001.
Amended by Acts 2005, 79th Leg., ch. 269, § 1.49(2), eff. Sept.
1, 2005.
§ 157.055. ORDERS AND PROTOCOLS. A 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, an order or protocol used by a
reasonable and prudent physician exercising sound medical
judgment:
(1) is not required to describe the exact steps that an
advanced practice nurse or a physician assistant must take with
respect to each specific condition, disease, or symptom; and
(2) may state the types or categories of medications
that may be prescribed or the types or categories of medications
that may not be prescribed.
Acts 1999, 76th Leg., ch. 388, § 1, eff. Sept. 1, 1999.
