Prescriptive Authority Agreement Explanation Page

***This page is not be included in your final agreement

For APRNs who are not considered facility based delegation must be thru a Prescriptive Authority Agreement (PAA) and it is recommended that “Prescriptive Authority Agreement” be used in the title. Facility based APRNs may choose to use a PAA for delegation but if they do so then all requirements of a PAA must be met. This includes the face to face monthly quality meetings with delegating physician. For must facility based APRNs it is more appropriate to use a “protocol”. Please see the Baylor Scott & White Health North Texas Division Delegation of Medical Acts and Prescriptive Authority Protocol for Nurse Practitioners and Clinical Nurse Specialists.

PAAs do not need to describe exact steps that APRNs must take and should be written so APRNs may use their education and judgment in order to provide care for patients

This document is a template and should be used as starting point in developing a PAA that reflects the APRN(s)’ practice. All parties to the PAA should participate in the development. The delegating physician(s) must determine what medical acts he/she will delegate. The document should be reviewed, signed and dated at least annually. It may be done more frequently if needed. This template is specifically for nurse practitioners and clinical nurse specialists. CRNAs and midwives have other laws/regulations related to their practice which were not reviewed while constructing this document therefore not included.

The material in the document that is italicized and highlighted in yellow is to provide clarification and direction. This material should not be included in the final agreement that will be signed by all participating parties. Please read the document carefully and use the material that is applicable to your practice. For instance there are some sections that have many options to choose from depending on what the delegating physician(s) chooses to delegate.

Quality improvement requirements for non-facility based APRNs are mandated by law. A face-to-face meeting must occur monthly until the 3rd anniversary of the date the agreement is executed and then quarterly. Meetings held between quarterly meetings may be thru electronic communication that includes video conferencing or the internet. The electronic method must permit each participant to view images of other participants. If primary delegating physician or physician group changes then the in-person meeting requirement is reset.

The PAA must include:

-name, address and all professional license number of parties to agreement (include DPS and DEA #s)

-nature of practice, practice locations/settings (name and address of each location in which PAA will be executed)

-types of categories of drugs or devices APRN may or may not prescribe (include any blood products)

-general plan for consultation and referral

-plan to address patient emergencies

-general process for communicating information between APRN and physician

-may designate physicians assuming QAI and supervisory duties on temporary basis (optional)

-describe a prescriptive authority QAI plan, specifying methods to document plan implementation. At a minimum the QAI plan must include a chart review (number of charts to be determined by physician and APRN) and nature & frequency of the meetings required in statue (face to face meetings)

-reviewed and signed annually

-may include other provisions that are not mandated

Other Documents that should be reviewed by all APRNs

- Quick facts for APRN Practice in Texas

- Physician APRN Facts

Other Documents that may or may not apply to your practice:

-Consultation Agreement Template

-Call Prescriptions on Behalf of APRN Template

Baylor Scott & White Health North Texas Division Prescriptive Authority Agreement for Nurse Practitioners and Clinical Nurse Specialists

This prescriptive authority agreement (PAA) is for the practice of Advanced Practice Registered Nurses (APRNs). The PAA is applicable to the practice of Nurse Practitioners and Clinical Nurse Specialists who are associated with or employees of The Baylor Scott & White Health North Texas Division or applicable partners.

Purpose [optional section]

This PAA authorizes the APRN(s) to perform medical acts, including prescribing and ordering drugs and medical devices and receiving and distributing drug samples, in accordance with the Nursing Practice Act, §301.152, Texas Occupations Code and the Medical Practice Act, §157.051 – 157.060, Texas Occupations Code. This PAA delegates certain medical acts, as authorized or required by Texas law, and sets forth guidelines for collaboration between the delegating physician(s) and the APRN(s). This agreement is not intended to limit the healthcare services the APRN(s) shall provide under his or her scope of practice, based on the advanced practice role and specialty authorized by the Texas Board of Nursing (BON).

Development, Revision, Review and Approval [optional section]

The PAA is developed collaboratively by the APRN(s) and delegating physician(s). ThePAA must be reviewed annually, dated, and signed by all the parties named in the PAA. Alternate physician(s), if designated,are not required to sign the document. The PAA may be revised more frequently as necessary. With the exception of amending the list of alternate physicians, if designated, amendments must be signed and dated by all parties. Any changes to documents referenced in the PAA, must also be approved by all parties to the agreement.

Signing the “Statement of Approval” signifies the partiesapprove the agreement and all policies, protocols and/or procedures referenced in this document. The parties are entering into a collegial relationship in which each party understands and will fulfill his/her legal responsibilities under the terms of the agreement. APRNs and any delegating physicians who join the staff after approval or renewal of this agreement will also review and sign the agreement. APRNs must sign the agreement before prescribing or ordering any drugs or medical devices.

Each APRN and physician must retain a signed copy of the agreement until the second anniversary after the delegating relationship is terminated.

Requirements and Disclosures [optional section]

The APRN must be licensed in good standing as a Registered Nurse and as an APRN with prescription authorization from the Texas Board of Nursing in a role and population focus area appropriate to the population of patients for whom the APRN will prescribe or order drugs and medical devices. APRNs shall not be a party to a PAA if under a Board Order prohibiting their participation. If prescriptive authority for controlled substances is delegated, the APRN must also have a Texas Department of Public Safety Controlled Substances Permit and a Drug Enforcement Agency (DEA) certificate. The APRN must also possess a valid Basic Life Support (BLS) and Advance Life Support Certificate (ACLS) in accordance with facility or practice policies in which they practice.

Each delegating physician must hold a full and unencumbered Medical License issued by the Texas Medical Board. The physician is limited to delegating to no more than the full-time equivalent (1 FTE = 50 hours) of seven APRNs and physician assistants.

Before executing this agreement, the physician and APRN must disclose to all other prospective parties any prior disciplinary action taken by the respective licensing board. Within 30 days of executing this agreement, the physician and APRN must complete the Texas Medical Board’s “Prescriptive Delegation Registration.” Any party to this agreement will notify the other parties immediately if, at any time while this PAA is in effect, a licensing board notifies the person he/she is under investigation.

Nature of the Practice and Locations

The APRNs will treat [insert the type of practice and population of patients to be cared for by APRN, ex: adult and gerontological patients admitted to the xx service, patients of all ages in a facility based hospital emergency room] at the following practice site(s):

Include facility name, complete address

Name, Address and Professional License Numbers of Parties to the PAA[Add as many rows to table as necessary, may include this information on signature page rather than place here. APRNs must list TX DPS and DEA numbers if physician is delegating prescriptive authority for controlled substances.]

______
Delegating Physician’s Name and Professional Title TMB License # TX DPS # DEA #
______
Address City State Zip Code
______
Delegating Physician’s Name and Professional Title TMB License # TX DPS # DEA #
______
Address City State Zip Code
______
APRN’s Name and Professional Titles RN License # APRN License # Rx Auth #
______
TX DPS # DEA #
______
Address City State Zip Code
______
APRN’s Name and Professional Titles RN License # APRN License # Rx Auth #
______
TX DPS # DEA #
______
Address City State Zip Code

Delegation of Prescriptive Authority and Medical Acts [This section should be modified in accordance with medical acts being delegated]

The APRN may establish medical diagnoses for patients who are within the APRN’s scope(s) of practice, and order or prescribe drugs. The APRN may order/prescribe medical devices, including medical supplies, durable medical equipment, prosthetics or orthotics as authorized by the Texas Board of Nursing and the Texas Medical Board rules and regulations. The APRN may also receive and distribute samples for drugs they are permitted to prescribe. These services/functions are not an exhaustive description of the APRN practice but rather illustrative of the types of medical aspects of care the APRN will perform. The APRN may perform medical functions and procedures as privileged by the facility in which the APRN provides care. These functions include, but are not limited to, performing physical examinations and medical histories, ordering and interpreting laboratory tests and radiologic exams, providing health promotion and safety instructions, evaluation and management of acute episodic illnesses and stable chronic diseases, and referrals to other health care providers, as needed.

A. Prescriptive Authority

The APRN(s) may order or prescribe:[The law states that physicians may delegate ordering and prescribing nonprescription drugs but there is no requirement to further specify categories of these drugs. The PAA, however, must specify the drugs or categories of Dangerous drugs that may or may not be ordered or prescribed. If no limitations, specify that all categories of dangerous drugs are included, or if there are limitation, specify those limitations. Other options might include drugs that may or may not be generically substituted and the number of refills the APRN may prescribe. No limitations are required by law. The legal definition of “dangerous drugs” includes medical devices. Therefore, if there are any limitations of prescribing medical devices, also note that in this section and modify other suggested language, as necessary.]

  1. Nonprescription and Dangerous Drugs (The term includes a device or a drug that bears or is required to bear the legend: "Caution: federal law prohibits dispensing without prescription" or "RX only" or another legend that complies with federal law)

A[choose one statement]

The APRN(s) may order and prescribe all categories of nonprescription drugs and dangerous drugs that are within the APRN’s scope of practice without limitations on dosage units or refills other than those listed elsewhere in this protocol.

The APRN(s) may order and prescribe all categories nonprescription drugs and of dangerous drugs that are within the APRN’s scope of practice without limitation on dosage units or refills, except those listed elsewhere in this protocol and for the following:

BWhen prescribing dangerous drugs, generic substitution for all drugs is permitted.

C The APRN may prescribe investigational drugs as part of a research protocol as directed by his or her supervising physician

D BON Rule 222.4 (e) limits the drugs APRNs may prescribe to those that are FDA approved unless part of a research protocol or the APRN can show evidence-based research that prescribing the drug is within the standard of care for the disease or condition being treated.

2.Controlled Substances, Schedules III - V[these limitations are required by law. May specify any other limitations the delegating physician places]

ALimited to a 90-day supply or less

BNo new prescriptions or refills after the initial 90-day supply without prior consultation with the physician.

CNo prescription for children under 2 years of age without prior consultation with the physician.

DPrior consultation must be noted in the patient’s record.

EIn accordance with §481.071, Health & Safety Code, an APRN may not prescribe an anabolic steroid or human growth hormone listed in Schedule III.

3. Controlled Substances, Schedule II

[Non-facility Based]

The APRN(s) may not sign a prescription for a Schedule II Controlled Substance to be filled by an outpatient pharmacy under this PAA agreement. Pursuant to the standing medical order below, the APRN(s) may select and write dispensing and administration directives for the following Schedule II Controlled Substances for administration to hospital in-patients or for patients being treated in the emergency room or out-patient setting within the parameters specified below.

  1. The APRN(s) with prescriptive authority from the Texas BON may only execute this standing medical order in[specify each practice facility by name].
  2. The signs and symptoms requiring treatment with Schedule II Controlled Substances are: severe pain related to acute and chronic illnesses or shivering as applicable[may include additional criteria as applicable]
  3. The Schedule II Controlled Substances that may be prescribed include:

Drug / Dose Parameters / Frequency parameters
Morphine Sulfate
Hydromorphone (Dilaudid)
Fentanyl
Codeine
Oxycodone
Methadone
Demerol

[Facility Based or HospiceNPs/CNS. Applies only to APRN seeing hospice patients, patients being treated in a hospital ER or admitted as inpatient with estimated length of stay greater than 24 hours. The setting in which the APRN may prescribe these drugs should be specified]

APRNs may order and prescribe the following categories of Schedule II Controlled Substances for [choose applicable statement: hospice patients, patients in the hospital emergency room, and/or hospitalized inpatients with an intended length of stay greater than 24 hours]:

Opiates to manage pain [list other symptoms, as appropriate]

Stimulants to manage fatigue

Depressants to manage sleep disturbances

4. The APRN may prescribe all blood products as applicable for patient care.

B. Drug Samples[optional section, however includes information that is difficult to obtain and the BON requires APRNs to maintain this documentation]

The APRN(s) may accept, sign for and distribute prescription drug samples. The APRN(s) must retain any receipt they sign when receiving drug samples. In addition, the APRN must note in the patient’s chart any sample distributedand comply with BHCS facility policy on the documentation and/or distribution of drug samples. The date, drug, dosage, frequency and duration of treatment must be noted in the patient’s chart and included on the sample distributed to the patient. The APRN may also wish to maintain a record of distribution that includes the date of distribution, the patient’s name, the name and strength of the drug, the lot number, and/or directions for use.

C. Persons Who May Call Prescription to the Pharmacy as Directed by the APRN [optional section]

The physician designates any licensed vocational nurse or registered nurse working or volunteering in this site as a person who may orally transmit a prescription into a pharmacy on behalf of the APRN(s). A list of the person authorized to orally communicate prescriptions to the pharmacy must be maintained at the practice site and will be made available to a pharmacist upon request. [Any such person(s) should be designated by name and can be listed here or elsewhere]

D. Medical Procedures [optional section][this section is to identify medical procedures the APRN may perform that would not be within the APRN’s normal scope of practice. It should not include procedures that all RNs can perform and those commonly performed by this type of APRN. List procedures that require training beyond that usually taught in most educational programs for the APRN’s role and population focus. However if want to include it is acceptable to list procedures that are standard for APRNs practicing on a particular service or may refer to job description or privileging documents].

The APRN may perform medical procedures in accordance with their education and training as specified on facility privileging documents.

E. Medical Verifications for Disabled Parking Placards[optional section, no need to include if this does not apply to the APRN’s practice. However delegation is required so if it is not included then the APRN is unable to sign verification for initial application of disabled parking placard]