Prescribing in Texas

Overview of APRN Prescriptive Privileges in Texas

Updated August 2019

There are two primary limitations on prescriptive authority for Advanced Practice Registered Nurses (APRNs) in Texas.

1. Prescriptive Authority must be delegated by a physician through a written document prescribed by law; and
2. Certain limitations apply to prescribing Controlled Substances (CSs).

Site-Based and Distance Restrictions Eliminated

Since implementation of SB 406 on November 1, 2013, physicians may delegate prescriptive authority to APRNs in any location in Texas. Site and distance restrictions no longer exist, and requirements for physician supervision are now the same for all physicians delegating through a Prescriptive Authority Agreement (PAA).

Physician Delegation

Drugs and Devices a Physician may Delegate

According to TMB Rule 193.6, physicians may delegate ordering and prescribing nonprescription drugs, prescription drugs and medical devices (legally designated as “dangerous drugs”), and durable medical equipment to an APRN or physician assistant (PA).[i] Physicians may also delegate ordering and prescribing Schedules III-V Controlled Substances subject to four limitations.

1. The duration of the prescription, including refills of the original prescription, may not exceed 90 days;
2. Continued treatment with the same controlled substance beyond 90 days requires consultation with the delegating physician prior to writing another prescription or refilling the original prescription;
3. Prescribing CSs for a child under age two years requires prior consultation with the delegating physician; and
4. Consultation with the physician must be noted in the patient’s medical record.

Physicians may also delegate ordering and prescribing Schedule II Controlled Substances to a narrow range of APRNs and PAs who are:

1. treating terminally ill patients cared for through a qualified hospice care provider;
2. facility-based in a hospital and treating patients in that hospital’s emergency department; or
3. facility-based in a hospital and treating patients admitted for an intended length of stay of 24 hours or longer.

Other Medical Acts a Physician may Delegate

While not specifically addressed in the Medical or Nursing Practice Acts, the BON Rules refer frequently to physician delegation of “ordering or prescribing drugs and other medical acts.” Those medical acts may include, but are not limited to, medical diagnosis, signing medical verifications for temporary disabled parking placards, and ordering respiratory, prosthetic and orthotic care for patients.

Physician Supervision

• Physician supervision 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 advanced practice registered nurse or physician assistant. A physician shall provide continuous supervision, but the constant physical presence of the physician is not required” (22 TAC §193.9[c][6]).
• According to TMB Rule 193.11, physicians must have a method to track prescriptions written by the APRNs and PAs to whom the physician delegates.
• In addition to the requirements above, physicians who delegate prescriptive authority through a Prescriptive Authority Agreement must perform a chart review and meet with the APRN monthly.

Prescriptive Authority Agreement (PAA)

The PAA is one of two possible written documents through which physicians delegate prescriptive authority to an APRN and/or physician assistant (PA). The requirements for physicians, APRNs and PAs entering into a PAA are contained in Texas Medical Board (TMB) Rule 193.7 . The rules specific to APRNs that are parties to a PAA are in Texas Board of Nursing (BON) Rule 222.5.

Qualifications to be a party to a PAA

APRNs must:

1. have a full and active APRN license issued by the BON;
2. have a valid prescriptive authorization number issued by the BON;
3. be in good standing (Both the license and prescriptive authorization number are not encumbered by a disciplinary action and the BON is not currently prohibiting the APRN from executing a PAA.);
4. disclose any previous or current disciplinary action against the APRN’s license; and
5. after entering into a PAA, immediately disclose if notified the BON is investigating the APRN.

Physicians (M.D. or D.O.) must:

1. have a full license to practice medicine issued by the Texas Medical Board (Physicians with some restricted licenses such as public health, telemedicine, etc. might be permitted to delegate prescriptive authority under certain circumstances, but this requires a determination by the TMB);
2. disclose any previous or current disciplinary action against the physician’s medical license; and
3. after entering into a PAA, immediately disclose if notified the TMB is investigating the physician.

Content the written PAA must include:

1. The name, address, and all professional license numbers of the parties to the agreement;
2. Brief description of the nature of the practice, location or setting;
3. Either the types or categories of drugs and devices the APRN may order and/or prescribe or the types or categories of drugs and devices the APRN may not order or prescribe;
4. A general plan for consultation and referral;
5. A plan for addressing patient emergencies;
6. The general process for communication and sharing information related to the care and treatment of patients;
7. A prescriptive authority quality assurance and improvement (QAI) plan that, at a minimum, includes a chart review (identifying the number and how the physician will review charts) and monthly meetings, and describes how implementation of the QAI activities will be documented;
8. Signatures by all parties to the agreement with the date the physician or APRN signed the PAA.

Optional Content the PAA may include

1. Other medical acts the physician is delegating
2. Alternate physicians
3. Treatment guidelines, protocols, or references that are used by all providers in the practice

Monthly QA Meetings

A bill passed in 2019 that simplified the language requiring monthly meetings. All meetings may be virtual, but they must be held via a real-time, HIPAA compliant platform.

Revision and Renewal

At a minimum, the PAA must be reviewed, and as necessary revised, annually. Upon annual review, all parties must sign and date the agreement.

Limitations on the Number of APRN/PAs to Whom One Physician may Delegate

With the two exceptions listed below, physicians are limited to delegating to a maximum combined number of seven APRNs and/or PAs, or their full-time equivalents (FTEs). The TMB considers a FTE to equal 50 hours. Therefore most physicians are limited to delegating to APRNs and PAs that work a maximum of 350 hours per week.

Exceptions

Physicians delegating to APRNs and PAs in two types of practices are not subject to any limit on the number of APRNs to whom they may delegate prescriptive authority. Those types of practices include:

1. Medically underserved -“Practice serving a medically underserved population” is defined in TMB Rule 193.2(14) and BON Rule 222.1(17); and
2. Facility-based practices in a hospital licensed as general, mental or special hospital, including hospitals maintained or operated by the State of Texas. The physician is limited to delegating under the facility-based provision at only one hospital.

Physicians who delegate prescriptive authority in a facility-based practice (hospital or long-term care) may also delegate to a maximum of seven additional APRN/PA FTEs under the terms of a PAA.

Facility-Based Practices/Sites

According to TMB Rule 193.9 and BON Rule 222.6, facility-based practices occur in two settings.

1. hospitals; and
2. long-term care facilities (includes  licensed nursing facilities. assisted living facilities, or intermediate care facilities for individuals with intellectual disabilities [ICF/IID])

In these practices, the APRN usually cares for many physicians’ patients, not just those admitted by the delegating physician. However, the facility must obtain permission from physicians before the APRN may participate in caring for another physician’s patients.

The boundaries for a hospital facility-based practice are within the walls of the physical facility. APRNs may be facility-based if working in an outpatient department located in the hospital, but practices located in professional buildings, even on the hospital grounds, do not qualify. Therefore, even if a hospital owns freestanding emergency rooms, clinics and physician practices, none of these freestanding entities qualify under the facility-based rules.

Physicians who may delegate in facility-based practices

One of the distinguishing features of a facility-based practice is the limitation on the types of physicians authorized to delegate under the facility-based provisions. In hospital facility-based practices, prescriptive authority must be delegated by the:

• medical director,
• chief of medical staff,
• chair of the facility’s credentialing committee,
• department chair, or
• a physician who consents to a request from the medical director or chief of medical staff to delegate prescriptive authority to a APRN that practices in that facility.

The physician may only delegate under the facility-based provisions in one hospital.

In a long-term care facility-based practice, only the medical director may delegate prescriptive authority. The medical director may delegate prescriptive authority in a maximum of two long-term care facilities and to a maximum of seven APRNs and PAs (FTEs).

This is not to be construed to mean that other APRNs may not order drugs for patients in a hospital or long-term care facility. Other physicians who have admitting privileges in the facility may delegate prescriptive authority to APRNs with whom they work through a PAA. However, one of the primary benefits of qualifying as a facility-based site is the fact that physicians in facility-based practices may delegate prescribing and ordering drugs and medical devices through Protocols or other written authorizations. Therefore, the physicians delegating through one of those alternate mechanisms are not required to meet monthly, perform chart reviews, and meet the other mandatory PAA requirements.

Facility-based Protocols

“Protocols” is the written document through which physicians delegate prescriptive authority in facility-based practices. Protocols is the legally defined term in Texas, but it is confusing since the term is commonly used in facilities to denote actions taken in response to specific symptoms or conditions. Since the common definition is inconsistent with the legally defined term, when referring to facility-based protocols for delegation of prescriptive authority, the terms, “Protocols” and “Protocol” are capitalized on this website.

The definitions of “Protocols” in TMB Rule, 22 TAC §193.2(18) and BON Rule, 22 TAC §222.1(21) and 222.6(b) include very little mandatory content. At a minimum, the Protocols must include:

• a signature page with dates to demonstrate that the physician and APRN met the mandatory requirement for annual review; and
• the drugs the APRN is, or is not, permitted to prescribe or order. If the physician elects to include the categories of drugs the APRN or PA may order or prescribe, then additional information is required, including:
• limitations on the number of dosage units and refills permitted, and
• instructions to be given the patient for follow-up monitoring.

As a consequence, the simplest and safest approach from a risk management standpoint may be to include a very limited exclusionary list of drugs or categories of drugs that APRNs working in this facility or department would never prescribe.

The Protocols should include the other medical acts the physician is delegating, and may include other optional content that is listed earlier in this article. The physician and APRN should consider including a quality assurance and improvement plan, especially if the facility does not include APRNs in the facility’s Focused and Ongoing Professional Practice Evaluation processes.

The parties must update the Protocols, and any treatment guidelines identified in the Protocols, as often as necessary for consistency with current physician delegation, practice, and facility-bylaws and policies. At a minimum, the parties must review, revise (as necessary), sign and date the Protocols annually. The APRN must keep a current copy of the Protocols for his/her records and at each practice location so it is easily available for reference or for review by other staff or regulators.

Prescriptive Authority Requirements to Remember

1. All APRNs who are ordering or prescribing controlled substances under the terms of a PAA or Facility-Based Protocols must have a controlled substances registration number from the DEA.
2. Physicians who delegate prescriptive authority through a PAA must register the delegation with the TMB within 30 days of signing the PAA, and must terminate the registration within 30 days of terminating the agreement. The registration process also requires the APRN to complete a portion of the registration before the physician completes it.
3. All parties to a PAA must maintain documentation throughout the period in which the physician delegates prescriptive authority and for two years after the date the physician terminated delegation. Facility-Based Protocols should be retained in accordance with facility policies, and it is advisable for parties to the Protocols to retain the Protocols and associated documents for two years from the date of termination.
4. Physicians must have a method to track prescriptions written by the APRNs and PAs to whom the physician delegates.
5. APRNs prescribing controlled substances must be comply with additional requirements and limitations. Read Prescribing Controlled Substances in Texas.

Other Resources

CNAP produces a “Sample Prescriptive Authority Agreement” and “Sample Facility-Based Protocols.” For comprehensive information on prescriptive authority and many other practice issues for APRNs, purchase A Guide for APRN Practice in Texas. The three documents are available for purchase online.

Information that must be included in a prescription and on a prescription form is in BON Rule 222.4. Applications for prescriptive authority numbers and other essential information for APRNs is posted on the BON’s Advanced Practice Nursing Webpage. To read FAQs on prescriptive authority that the BON and TMB jointly developed, see the BON and TMB Websites. (For the TMB’s FAQs, click on “Laws and Rules” in the left navigation column.)

Chart Comparing Prescriptive Authority Before & After 2013 Law

Controlled substances  prescribing requirements.

Endnotes

[1] Physician Assistants may be parties to a PAA. The law in Texas on delegated prescriptive authority is exactly the same for APRNs and PAs.

[2] If the APRN has had delegated prescriptive authority and actively utilized that authority for five of the past seven years, the monthly meetings must be in-person for one year. If the APRN does not meet this requirement, the APRN and physician must meet in-person for three years. Thereafter the physician and APRN must meet in person quarterly with monthly meetings in between by a method of telecommunications that allows real time communication such as secure videoconferencing (22 TAC §193.8[11] and 22 TAC §222.5[d]).