Q. In managing physician assistants and advanced practice registered nurses, what is the difference between a prescriptive authority agreement and a protocol? Do I need to have both?
A. Physician assistants (PAs) and advanced practice registered nurse (APRNs) must have delegated authority to provide medical aspects of patient care under Texas law, such as through a protocol or other written authorization. Rather than having two documents, you can include this delegation in a prescriptive authority agreement if both parties agree, the Texas Medical Board (TMB) says.
The Texas Medical Board’s rules define a protocol as “written authorization delegating authority to initiate medical aspects of patient care, including delegation of the act of prescribing or ordering a drug or device at a facility-based practice.”
The definition further states that “[t]he term protocols is separate and distinct from prescriptive authority agreements as defined under” the Medical Practice Act and related rules. However, prescriptive authority agreements “may reference or include the terms of a protocol(s).”
The rules contain additional requirements for protocols. They must be:
- Agreed upon and signed by the physician and the PA or APRN,
- Reviewed and signed at least annually, and
- Maintained on site.
The rules also place requirements for these protocols regarding types of drugs permitted or prohibited, limitations on dosages or refills, and patient instructions for follow-up. The protocols need not describe the exact steps a PA or APRN must take regarding each specific disease, condition, or symptom. It may state the types or categories of medications a PA or APRN may or may not prescribe.
Prescriptive Authority Agreement
The Medical Practice Act defines a prescriptive authority agreement as “an agreement entered into by a physician and an advanced practice registered nurse or physician assistant through which the physician delegates to the [PA or APRN] the act of prescribing or ordering a drug or device.”
A key feature of these prescriptive authority agreements is that they can be individually tailored — “customized” — to fit the needs and circumstances of the practice relationship between the physician and the PA or APRN. The physician who is delegating and supervising the PA or APRN must enter into a prescriptive authority agreement, which addresses and documents various elements of the relationship and supervision, to delegate prescriptive authority in nonfacility-based practice settings.
A prescriptive authority agreement must contain certain elements. It must:
- Be written, signed, and dated by the parties to the prescriptive authority agreement;
- State the name, address, and all professional license numbers of the parties to the prescriptive authority agreement;
- State the nature of the practice, practice locations, or practice settings;
- Identify the types or categories of drugs or devices that may or may not be prescribed;
- Provide a general plan for consultation and referral;
- Provide a plan for addressing patient emergencies;
- State the general process for communicating and sharing information about patient care and treatment between the physician and the APRN or PA;
- Designate one or more alternate physicians to provide supervision, if alternate physician supervision is to be used on a temporary basis, and require that the alternate physician participate in the prescriptive authority quality assurance and improvement plan; and
- Describe a prescriptive authority quality assurance and improvement plan, specifying methods for documenting the implementation of the plan (including chart review and periodic face-to-face meetings).
There also are requirements applicable to the frequency, documentation, and content of the periodic face-to-face meetings.
For details, see “Delegation of Duties by a Physician,” a 2017 white paper of the TMA Office of the General Counsel (TMA log-in required). Also check out these TMA resources for managing PAs, APRNs, and other nonphysician practitioners:
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