- [John] In this section of our scope of practice lecture,
we will review Texas laws and how they impact and affect
the AGACNP scope of practice.
This, again, is specifically for Texas
and does not apply outside of Texas.
So if you're not a Texas resident,
or not getting licensed in Texas,
you do not necessarily need to listen to this lecture.
So these are the specific Texas laws we will look at
and we'll start with the Texas Board of Medicine.
You are an AGACNP working for an intensivist group
who provides telemedicine consultation services
to a rural hospital without an intensivist program.
What Texas law or rule governs telemedicine practice
and is this within the scope of practice?
So we're gonna answer these two questions
in the next couple of slides.
So we do have a law, and it's the Texas Occupational Code,
Title 3 Health Professionals, Chapter 111 Telemedicine,
that does discuss the requirements of telemedicine.
What this says is it says a treating physician
or health professional who provides or facilitates the use
of telemedicine medical services or telehealth services
must obtain informed consent prior to providing services.
So that informed consent is essential
before you even start services.
This law requires that patient confidentiality
is maintained.
It requires that a valid patient provider relationship
exists as long as the practitioner complies with
the standard of care.
The visit must be a synchronous audiovisual interaction
between the practitioner and the patient.
So doing a telephone call to the patient
is not considered a telemedicine service under state law.
It has to be an audiovisual thing.
The practitioner is required to provide guidance
on appropriate follow up care and if the patient consents
and has a PCP, the practitioner must provide the records
or a report to the PCP within 72 hours.
Cannot prescribe a drug used for abortion
via telemedicine services.
And chronic pain cannot be treated
using telemedicine services.
What was on the previous slide about telemedicine
was just in the general health and safety code of Texas law.
That is the law that gave the authority
to the Texas Medical Board
to write rules and regulations on telemedicine.
And so what we're going to look at now
is the specific Texas Medical Board rules.
So their law or rule has been around for a while
but, as of May 22 2017 it changed telemedicine.
The law changed dramatically with the passing of SB 1107.
So the law has been streamlined
and is actually more lenient now than what it was.
So this law does require physicians,
who use telemedicine services, to adopt protocols
to prevent fraud and abuse through the use of telemedicine.
Physicians must provide patients
with their privacy practices
if they communicate with the patient
with any electronic means other than telephone or facsimile.
They must obtain the patient's written
or electronic acknowledgement of receipt of the notice.
A licensed practitioner is expected to meet
the standard of care and demonstrate
professional practice standards and judgements,
consistent with all applicable statutes and rules
when issuing, dispensing, and delivering or administering
a prescription medication as a result of
a telemedicine medical service.
So, in other words, they're saying in that statement
that the practitioner is required to follow
the standard of care and just because it's telemedicine
does not mean that the practitioner is relieved from
following those standard practices.
This is where the treatment of chronic pain
is specifically prohibited.
That's in the Texas Medical Board rules.
The treatment of acute pain with scheduled medication
is allowed as well, unless it is prohibited by federal law.
Then the health professional providing health care services
or procedure via telemedicine
is subject to the same standard of care
that would apply for any in person setting.
Okay, so let's go on to our next case scenario.
Your ACNP colleague calls you to discuss scope of practice.
He is working for an intensivist group
and just recently started the position.
He is expected to make rounds on ICU patients
during the day.
The physician and the NPs split the patients
and provide care to only their team of patients.
The physicians are available for consultation
but do not routinely see the patients the NP sees.
So what Texas law rule gives us direction for this scenario?
What other agency policies must be considered?
Is this appropriate?
Is this within the scope of practice?
So, let's look at our next slide
and we'll start answering these questions.
So the Texas Medical Board has a rule in it
that is called Standing Delegation Orders.
In this, it specifically says that a physician is not liable
for the acts of a physician assistant or an APRN,
solely on the basis of having signed an order,
a standing medical order, or a standing delegation order,
a Prescriptive Authority Agreement, or other protocol.
This law further goes on to say that
a physician may delegate authority at one hospital
or two long-term care facilities.
So it's important for you to know that
even though this is in the Texas Medical Board
because as you apply for positions in Texas,
you wanna make sure that this physician
is not overextending himself because,
if he is and you don't know,
you could be putting yourself at risk.
This law ultimately says, and it's in quote,
physician supervision of the prescribing and or ordering
of a drug or device shall conform to what a reasonable,
prudent physician would find consistent
with sound medical judgment
but may vary with the education and experience of
the APRN or physician assistant.
A physician shall provide continuous supervision,
but the constant physical presence of the physician
is not required.
So that is really the statement that answers the question
of the scenario that we just read on the previous slide.
Ultimately, that scenario is within the scope of practice.
It is appropriate to do, and the physician, as you can tell,
does not have to see all the patients
because that can be a determine based on the APRN
or PA's experience.
So that is okay to do but that nurse practitioner,
in that scenario, needs to know what their limits are,
needs to know when he needs to call the physician
and collaborate with him.
And furthermore, they need to know what the hospital by-laws
and policies allow.
So that question needs to go back
to the medical staff office and say,
is this okay that we're doing this.
Finally, this medical board rule does require that
the Registration of Delegation
and Prescriptive Authority Agreements
with the Texas Medical Board.
That means that the physician is required
to let the Texas Medical Board know
who they are delegating Prescriptive Authority to
and prescriptive privileges to.
So that this is done all electronically
and you can see the website there at the bottom
is where all this information came from.
So, I think this slide is our, let's see,
is what we just discussed.
So this is the NP making rounds in the hospital
and the physician's not seeing the patients.
I've already discussed this.
It is appropriate and it's highly dependent upon
what the hospital would allow.
If the hospital's okay with it,
the medical staff office is okay with it,
then it's perfectly okay.
But, again, the NP needs to know
when he or she needs to collaborate with the physician.
How does the Texas State Board of Pharmacy
regulate APRN practice in Texas?
So they have the Prescriptions Law,
it's Texas Occupational Code, Title 3, et cetera,
and in this law it mandates that
prescriptions of dangerous drugs be in compliance
with all state and federal regulations.
The Texas Administrative Code, Title 22, Part 15,
Chapter 315 of the Controlled Substance Act,
went into effect September 1st of 2016.
In this, it requires the use of Official Prescription Forms
to prescribe Schedule II medications.
These forms are, we, as nurse practitioners in Texas,
do not need these forms too often.
The only times that we can prescribe
Schedule II medications, as it stands right now,
is for patients who are in the hospital
or are in an emergency room that is attached to the hospital
and are expected to have greater than 24 hour stay
if they're admitted to the hospital.
So then we can prescribe a Schedule II medication
in our order of Schedule II medication, in that instance,
but to do that we don't need these special forms.
The other time that we can prescribe Schedule II medications
is for patients who are in hospice.
So if it's an outpatient hospice scenario,
then we may very well need these forms
to prescribe the Schedule II medications.
So that would be the only reason
that we would need these forms at this date and time.
So these forms have to be ordered
from the Board of Pharmacy.
The order form has to be cosigned
by the delegating physician.
Upon termination of the physician delegation,
the forms are void and they have to be returned
back to the Board of Pharmacy.
The state Board of Pharmacy says that we have to have
a DEA number.
I've already said the use of the official form
is not required for hospitalized patients
or patients in the ED.
It is required for hospice setting patients though.
Dos and don'ts with the form.
The Board of Pharmacy says do not pre-sign these forms.
That is dangerous so don't do it.
You have to keep them in a safe place.
Do not allow use by another practitioner,
so they are registered to you and only you.
So you do not give those out to somebody else to use.
All voided forms must be accounted for.
Lost and stolen forms must be reported
by the end of business day to the Board of Pharmacy
and to the local police and if they are recovered,
then before you use them,
on the day that you recover them,
before the end of day, you have to report that back
to the Board of Pharmacy and the local police as well.
In the event that a patient has lost their prescription,
the prescriber must report the patient's name, address,
date of birth, age, and all drug information
and official prescription form number
to the Board of Pharmacy.
The Texas State Board of Pharmacy
has a Prescription Monitoring Program,
which you must be registered to use that database.
So in Texas, we are now required,
before we give a prescription for medication,
for Schedule II medications,
to go into this Prescription Monitoring Program
and see that.
All the boards, the Board of Medicine,
the Board of Pharmacy, Board of Nursing,
are all now required to monitor our activities in there.
So this is something that you need to make sure
that you get registered for and that you have access to
and if you're going to write a prescription
for a scheduled medication,
you need to go into this database and check and make sure
they weren't just issued 30 pills last week
and now you're giving them 30 pills upon discharge.
That would be inappropriate
and reason for the Board of Nursing to step in.
Now let's start looking at the Texas Board of Nursing
regulations and rules.
So one thing that's important for you to know is that
as an APRN you are obligated still
to the Nurse Practice Act
and just because you are now a nurse practitioner
does not mean that you can not follow
the Nurse Practice Act.
It just means that you have more rules to follow.
So let's look at this first question.
Which of the following is the most appropriate way
to sign your name and credentials after you have received
licensure as an AGACNP in Texas?
John Smith AGACNP-BC, MSN,
John Smith AGACNP-BC,
John Smith RN, AGACNP-BC,
or John Smith RN, NP?
So hopefully you realized that the third bullet point
that uses the RN and the AGACNP title
is the most appropriate.
In Texas we are required to always hold ourself out
as a registered nurse even though we are
an advance practice nurse.
So you have to hold out that you're a registered nurse
and identify that you're a registered nurse
and you should be identifying what type of
nurse practitioner or what type of APRN you are.
So I've already said this but this is answering the question
that I just asked.
This rule is in Texas Occupational Code, Chapter 301 Nurses,
Subchapter 8, and it requires us to use our RN title
and the correct APRN title.
So the Texas Board of Nursing,
I'm wondering, for those of you who live in Texas,
if you knew that the Texas Board of Nursing had a rule about
RNs performing radiologic procedures.
Usually when I ask this question in class,
I get a lot of, no, I didn't know that.
And so they do and it's important that you understand this.
What this law says is that RNs performing
radiologic procedures outside of a hospital
which participates in Medicare,
or is accredited by Joint Commission,
must register with the Board of Nursing.
So there are those free standing radiologic centers
that if an RN works at doing procedures,
they must register with the Board of Nursing.
You can see that this law also states that
they must follow the other laws listed below,
or listed on your screen.
So the Texas Board of Nursing requires
a minimal education of APRN.
So for those of you who are mad because we made you take
patho and pharm and all those good things,
I know you don't think they're good,
this is part of the reason why.
'Cause the Texas Board of Nursing requires it
and you wouldn't be able to get licensed otherwise.
Also, national organizations require that,
national certifying bodies require that,
that you have these separate courses.
The Board of Nursing requires that you have a minimum of
500 non-duplicated hours in your role and specialty
and that your education is at the master's level or higher.
I put that in there just so you can get
a different perspective of the requirements
that we've put you through.
We're just not trying to be mean, I promise.
So additionally, the Texas Board of Nursing
specifically states that APRN titles are protected
in Texas and one cannot hold themselves out to be
an APRN with a specific title
unless they hold that license to do so.
APRN licensure requirements.
The Texas Board of Nursing says you have to meet
certain requirements in order to be licensed.
So you have to have a valid RN license
that is unencumbered in Texas.
You have to submit documentation
that the educational requirements have been met.
You must have at least 400 hours of current practice
in the role, for which you are applying,
within the last two years.
You have to have 20 hours of continuing education
specific to the population or role you're applying.
In order to renew, in Texas we do renew the APRN license
every two years, just like the RN license.
They mandate that you have a minimum of
400 hours of practice every two years
and there are continuing education requirements.
The Texas Board of Nursing has a rule which is 221.12,
that is titled Scope of Practice.
In this rule the Board recognizes that
the scope of practice is variable and dependent on
the education and certification of the APRN.
They state that scope of practice shall be defined by
the national professional specialty organizations
or APRN organizations recognized by the Board of Nursing.
APRNs may only perform those functions
which are within their scope of practice.
In this rule they say that the APRN scope of practice
shall be in addition to the scope of practice
permitted by an RN.
So they identify that the RN scope of practice
and the APRN scope of practice is different.
But why is it important for you to understand that this
Board of Nursing has this rule?
It is important because if it's a rule,
you are obligated to abide by it.
So in this rule, they say that national nursing policy
defines a scope of practice.
So you, by default, are responsible for understanding
what national nursing policy says about scope of practice
and following that.
Which is why we went through all of the various
scopes of practice and how it is defined by,
nationally from the national nursing organizations.
It is important that you understand that
so that you work within your scope of practice,
because if you ever have to defend your scope of practice
to the Board of Nursing,
an answer of I don't know will not protect you.
On the Board of Nursing website,
the Texas Board of Nursing gives us some general information
about scope of practice.
Again, this is not one of their rules
but this is just on this more information
on the scope of practice as they define it.
So this is separate from the rules.
We'll get back to discussing the specific rules in a minute.
But it's important that you understand
and know where this information is
because this is important for you to know
and this is how the Board of Nursing sees scope of practice.
So, if you ever go to the Board of Nursing website,
go to the main page and there's a link that says
scope of practice.
If you click on there, you'll see the APRN scope of practice
and they give us more information on the scope of practice.
So on this portion of the website,
they say that the scope of practice is defined as
those activities that an individual health care provider
performs in the delivery of patient care.
Scope of practice reflects the types of patients
for whom the advanced practice registered nurse can care,
what procedures and activities the advanced practice
registered nurse can perform, and influences the ability of
the advanced practice registered nurse
to seek reimbursement for services provided.
They identify that there are two types of scope of practice
and that is the professional scope, which,
according to Board Rule 221.12,
is defined by the national APRN organizations
that are recognized by the Board.
Then they also identify that there's an individual
scope of practice.
They define the individual scope of practice as based on
the education, licensure, and certification
of the individual.
They do recognize it evolves over time,
based on your work experience, but there are finite limits
to the expansion of the individual scope of practice
without going back to school.
So, in other words,
you can expand your individual scope of practice
but it still has to remain within the scope of practice
as defined by the national nursing organizations.
So, as an acute care NP,
if you worked in the hospital service for 10 years
and decided you want to go into critical care
and learn how to drop lines and do critical care stuff,
you could do that and that would be within
your individual scope of practice
and your national scope of practice.
But, for instance, for an FMP who says now I wanna work with
critical care patients, I wanna learn how to intubate,
et cetera, that would not be within
their individual scope of practice
or their national scope of practice
and on the job training would not prepare them
for that role.
Therefore they would have to go back to school
and go through an acute care NP program,
and sit the certification,
get licensed in order to do those tasks.
Likewise, if an acute care NP wanted to do something
that fell within the primary care NP scope of practice,
they would have to go back and get formal education,
certification, licensure to do that.
Again, on the Board of Nursing's website
where it talks about scope of practice,
they give us some questions that really help us
guide our decisions about whether something, an activity,
a procedure, et cetera, is within our scope of practice.
So these questions that they provide on their website
help us to determine that.
So they recommend these questions.
The first question is, is it consistent with
one's professional scope of practice?
So, in other words, is it consistent with
how the national nursing organization
has defined your scope of practice?
If yes, you're in good shape.
Is it legal?
That's what the second bullet point says.
And legal doesn't mean just state.
It also means federal.
So if it's legal for you to do it,
then it's within your scope of practice.
Is it consistent with one's education
in the role and specialty?
So if it is, if you were educated and it's consistent with
your role, then you are likely to be able to do it.
The next bullet point is, is it consistent with
the scope of one's recognized title?
If so, then you're okay.
Or does it evolve into another advanced practice title,
recognized by the Board,
requiring additional formal education and legal recognition?
If it evolves into another title,
and I kinda discussed that already on the previous screen,
then it's not within your scope of practice.
Is it consistent with the standards of nursing practice
outlined in 2.17?
In that rule of 2.17 says that we have to promote
interventions that are safe.
We have to make referrals
and we only accept those assignments
that we are educationally prepared for.
So if what you wanna do is consistent with
Board Rule 217.11, then it's within your scope of practice.
Is it consistent with evidence-based care?
If yes, you're good.
The Board of Nursing requires that we practice
evidence-based care.
So that's why this is the question here.
We can't just willy-nilly decide to prescribe something
with no evidence behind it.
Is it consistent with reasonable and prudent practice?
That is a judgment call but if you can answer yes to that
then you're in good shape.
And then finally, are you willing to accept accountability
and liability for the activity and outcomes?
If yes then you're good to go.
So the Core Standards of Nursing Practice.
This is one of the Board of Nursing rules
and it's specifically rule 221.13.
We, again, as we go through
the Texas Board of Nursing information,
most of these are the rules that the Board of Nursing
have made that apply to APRN practice
and so the title at the top, for instance, on this screen,
is Core Standards of Practice.
That is the name of the rule, 221.13.
So most of these Texas Board of Nursing slides
are named after the rule
and we're discussing the specific rule and how it applies
to your nursing practice.
All of these are important for you to know
because they impact your practice.
So in the Core Standards of Nursing Practice for APRNs,
the Board of Nursing requires the following.
APRNs shall conform to Texas Nurse Practice Act.
All current board rules, regulations,
standards of professional nursing, all federal, state,
and local laws, rules and regulations
affecting the APRN role.
So in this Board rule, they tie you into knowing everything
and being accountable for knowing everything.
Nursing policy, the Nurse Practice Act,
all the rules and regulations, federal, state and local law.
So it's important that you have an understanding of
all of that, which is why we go through
as much as we go through in these lectures
on scope of practice.
This rule also states that APRNs must practice
within their scope of practice and it states
when providing medical aspects of care,
APRNs must work under a protocol or written authorization.
The authorization must be developed by the APRN
and physician together.
It has to be signed by both parties
and signed and reviewed annually.
It must be maintained in the practice setting of the APRN
and must be available as necessary
to verify authority to provide medical aspects of care.
Also, this rule specifically states that
APRNs retain professional accountability
for advanced practice care.
That's really important for you to know
because just because a physician cosigns an order
or signs a practice agreement for you
or delegation agreement,
that does not mean that they are responsible for
your actions.
So you specifically and me specifically,
we individually specifically hold accountability
for our practice as APRNs.
So the Board of Nursing requires continuing education
of us as nurse practitioners.
We have to have the 20 hours every two years
specific to our role, our APRN role.
If you maintain current certification in your role
you can meet this requirement.
You don't have to do the extra 20,
however you need to make sure that you have
the specific additional categories that are required.
So APRNs with Prescriptive Authority
need five additional hours in pharmacotherapeutics
per two years.
If you're prescribing controlled substances,
you need an additional three hours of controlled substances.
CME education approved are credited for physicians
is appropriate to use as your continuing education
and then APRNs and nurses who work in the ED
have to have continuing education
on forensic evidence collection
and that must be done before they do their first exam.
Additional requirements, APRNs who treat tick borne disease
should have continuing education within their role
and population focus
related to the treatment of these diseases.
We're still obligated to have the
Nursing Jurisprudence and Ethics every two years,
a minimum of two hours,
and then we also have to have two hours of CEs
required to geriatric care every two years.
So the rule that governs Prescriptive Authority,
that's what we'll talk about next.
You may be, this is something that may get
a little confusing.
You may be an APRN and not have Prescriptive Authority.
When you apply to be a nurse practitioner or another APRN,
you have to apply for that
and then you have to apply for prescriptive privileges,
and if you don't apply for prescriptive privileges,
you will not be granted those privileges
and you will not be able to prescribe anything.
So what's the point?
So this rule outlines what is standard prescribing practices
and what is requirement.
This rule says we need a Prescriptive Authority Agreement
or facility based agreement to prescribe medications.
Must prescribe within our scope of practice.
Again, they're tying us into scope of practice.
We must comply with the chart review requirements
that are in the PAA or facility based agreement.
The prescription requirements include
the patient information, drug information, the DEA number
if it's a controlled substance, date, et cetera.
I'll let you read those things.
And then this law also states that
we may prescribe only those medications
which are FDA approved.
So if they're not approved by the FDA with their indications
or an FDA approved drug to be given in the US,
we can't prescribe it.
So there is some exceptions to this
according to the Board rules.
One of the exceptions is that if it is a research protocol,
we can prescribe it then.
And then the other exception would be
if the medication that we're prescribing
doesn't have an indication for it
but is a generally acceptable practice
that it's okay to prescribe.
A good example of that is Zofran.
Zofran does not have an indication for general nausea
and vomiting but we constantly prescribe Zofran
for nausea and vomiting 'cause it's a fairly safe drug.
So that's a good example of how it's not indicated
for what we prescribe but it's a generally accepted practice
and considered safe and so that would be okay to do
under the Texas State Board of Nursing.
So the Prescriptive Authority Agreement,
you will have an assignment in practicum
to do a Prescriptive Authority Agreement.
And so this is, we'll have a separate overview
on the Prescriptive Authority Agreement
but I'm gonna tell you what the law says about it now.
So this is the Board rule.
The Prescriptive Authority Agreement is the mechanism
by which APRNs are delegated the authority
to order or prescribe drugs or devices by a physician.
This agreement should be used
mainly in an outpatient setting.
It can be used for inpatient settings
but ideally it's best suited for an outpatient setting only.
If a nurse practitioner is working
both outpatient and inpatient,
they can use this for both settings.
The Board of Nursing says that it has to have
certain requirements in it
and so it has to be written down,
has to have the name and address of the practice.
All providers, license numbers and names have to be on it.
You identify the drugs which may or may not be prescribed.
One must provide a plan for consultations and referrals
and for addressing emergencies.
State the general process of communicating
between the APRN and the physician.
Describe a prescriptive quality assurance
and improvement plan.
The APRN may undergo quality reviews with another physician
if it is so designated
in the Prescriptive Authority Agreement.
A copy of this has to be maintained for two years
and then the physician must notify you
if they are being investigated by the Board of Medicine
and you must let the physician know
if you come under investigation by the Board of Nursing.
So just really quick about
the Prescriptive Authority Agreement.
This, again, is best suited for the outpatient setting.
Under this law, we are required,
when we use this Prescriptive Authority Agreement, to,
the quality assurance review portion of this rule
mandates that we have monthly meetings with our physician
to discuss cases in our prescriptive practices.
Those monthly meetings have to occur face to face
and they are ongoing for three years.
After those three years then those face to face meetings
happen every three months
and then you can do telephonic meetings every month.
But they still occur monthly but how they occur changes.
So ultimately, this can be very tedious
which is why I say if you're going to work
in the inpatient setting, you don't wanna use this
for the inpatient setting.
You wanna use this for the outpatient setting only.
That's ideal.
But you can, if you choose, use it for both.
So the other practice protocol
is called a Facility Based Practice protocol
and that's the name of what it's called in the Board rule.
So the Facility Based Practice protocol
is what you use on the inpatient side.
You can only use this on the inpatient side.
You cannot use this on the outpatient side.
And this is the protocol that is used to give authority
to the APRN to prescribe drugs and devices.
Again, this should be used only on the inpatient setting,
not in the outpatient setting.
You should have some type of quality process
defined in this protocol
but it does not need to be anywhere near extensive
as the PAA.
Remember, this has to be reviewed annually and signed.
You have to keep this for two years.
This rule allows for us to prescribe and order in a facility
in which the delegating physician is the medical director.
So I've got this last sentence highlighted in red,
or written in red, because it's very important.
'Cause this rule states that the APRN can only order
or prescribe drugs and devices for the care or treatment
of only those patients for whom physicians have given
their prior consent.
So under this law, a medical director for a group can do
all the delegation for the group.
So if there's 40 physicians in the group
and the medical director is over all 40 of those physicians,
then that medical director can sign your PAA,
or your Facility Based Agreement
and delegate for all the other physicians.
However, if one of those physicians says
that they do not want you seeing their patients,
based on this rule you cannot see their patient.
It's against the law for you to do it so you can't do it.
So you have to back away from it.
So you really have to know your physicians
if you're in a group that is that large.
So let's look at a case scenario.
The Acute Care NP is working for a hospitalist group
and the medical director has delegated authority
for the AGACNP to see the practice patients in the hospital.
Upon meeting a newly hired physician, Doctor Smith,
he tells the AGACNP, I do not believe in using
nurse practitioners to care for my patients.
How should you handle this?
Based on the Facility Based Practice rule,
you cannot see that physician's patients
and you just don't do it.
Say, it's against the law, can't do it, bye.
So the authority to prescribe controlled substances.
The Board of Nursing says this must be delegated
by a physician.
We can prescribe Schedule III through V medications.
We can give up to 90 days supply
and after 90 days of supply, if we need to order any more
we must consult with the physician and document that.
None of us can prescribe for children
if you're Adult-Gero Acute Care NP,
but the law does state you cannot prescribe
scheduled medications for children under two
without prior consultation with the physician.
The prescription of Schedule II medications,
we've already talked about, but it can only be done
in certain instances.
That is in inpatient hospital setting,
in a patient who is expected to have greater than
24 hours stay in the hospital,
or for a patient who is in the Emergency Department
that is physically attached to the hospital.
And that is key.
The ED has to be physically attached to the hospital.
Doesn't matter if the hospital owns it
and it's down the street from the hospital.
That ED wouldn't qualify.
And all these free standing EDs that are just popping up,
if you're an AGACNP working in there,
or a nurse practitioner working in there,
you can't prescribe Schedule II medications
in those free standing.
It has to be physically attached to the hospital.
So we can also prescribe the Schedule II medications
for patients who are receiving hospice care
from a qualified provider.
So conditions for obtaining and distributing drug samples.
In order to maintain drug samples,
one must have this in their collaborative agreement,
whether it's a PAA or a Facility Based Agreement
and this rule requires that drug samples be maintained
and labeled and logged with specific information.
So be aware of that.
It's not just easy peasy to do that.
So Texas Board of Nursing Enforcement
Rule and Case Scenario.
So where an AGACNP colleague tells you
she has an ear infection and has written a prescription
for herself to treat the infection.
Is this legal?
Can an AGACNP write an inpatient order for a patient
to receive Vancomycin
and have the pharmacy to dose the medication?
What Texas law gives us direction
to answer these two questions?
So it is the Enforcement Rule that is made by
the Texas Board of Nursing that answers this.
So the Enforcement Rule says that any APRN who violates
the sections of this rule or orders
or prescribes in a manner that is not consistent
with the standard of care shall be subject to removal
of the authority to order or prescribe under this section
and disciplinary action by the Board.
So this tells you what you cannot do.
So ultimately, it says, ordering and prescribing medications
or devices for anything other than evidence-based regimens
or prophylactic purposes, is inappropriate.
It says that prescribing for yourself is prohibited.
Prescribing without properly assessing and documenting
the assessment prior to the ordering prescribing treatment
is inappropriate.
So prescribing for a family member or a friend.
The friend comes to you and says,
oh I need this antibiotic, can you prescribe it.
Don't do it.
It's prohibited by the Board of Nursing.
So selling, trading, and offering to sell
medication samples, prohibited.
And then delegating authority to another person to order,
prescribe, or dispense an order or prescription
for a drug or device is prohibited.
So, in our scenarios that we just discussed,
the nurse practitioner wanted to prescribe
for her ear infection, that is prohibited.
She can't do it.
Then ordering a standing order of Vancomycin in the hospital
for the pharmacy to dose, that is okay.
But I bring that up because of the last bullet point
about delegating authority to another person
to order, prescribe or dispense.
And so in the instance where we ask pharmacy
to manage the medication, we're not delegating to them
ordering and prescribing.
We've ordered the medication.
We are taking an interdisciplinary approach
to the management of the patient
and it is a very safe and appropriate practice to do.
Okay.
So we've already answered these questions.
So we'll move onto the next slide.
So the Texas Board of Nursing has a rule
that discusses pain management.
In this rule it sets the minimum standards of care
that APRNs must meet in order to manage pain.
They want you to establish a goal of therapy.
They want you to prescribe medication
in only a therapeutic manner.
Treatment must be based on a complete assessment
and they hold you accountable for obtaining
a complete assessment prior to,
and documenting prior to prescribing pain.
The evaluation of pain must include a complete history,
a focused exam, nature and intensity of the pain,
all current and past medical treatment for this pain.
Any underlying conditions and co-existing
mental health issues need to be explored and documented.
The effects of pain
on the physical and psychological function
must be assessed and documented.
History and potential for substance misuse, abuse,
and dependence and addiction
must also be explored and documented.
They say that the treatment plan must be written.
That drug information must be given to the patients.
Labs and diagnostics must be ordered appropriately.
All treatment options that are planned or considered
must be documented and discussed with the patients.
There must be plans outlined
for ongoing monitoring and evaluation,
and measures must be implemented
to determine treatment outcomes.
Consultations and referrals must be made as appropriate
and documented.
And informed consent must be obtained
prior to treating the pain.
Now as you read this rule,
and I recommend that you all go in and read this rule
at the Board of Nursing,
it really feels as though it is talking about
chronic pain management versus acute pain management.
But nowhere in this rule does it say,
oh this is only for chronic pain management.
So it does apply to all pain management,
regardless of the inpatient setting
or the outpatient setting.
So anybody that's in a primary care
or a specialty office that is treating pain
needs to make sure that they have all this stuff
documented and up to date in the medical record
prior to prescribing medication for pain.
On the inpatient side, what I do is
I make sure that I have all the qualifying information
about the pain.
When did it start, is it constant, does it come and go,
what's the severity,
what has worked for your pain in the past,
what doesn't work, what makes it better,
what makes it worse?
Those type of things.
Does it radiate?
Then I'll look at the records and see what's been given
for pain and I ask them, has that worked specifically,
and I document all those
and then I prescribe my medications.
So at a minimum, I am doing all the things
that I need to acutely evaluate and manage that pain.
On the outpatient setting,
it may be a little more extensive.
Specifically if it is chronic pain management patients.
So you need to be familiar with this rule.
This is more information on this.
I've already talked about the acute care implications
on the inpatient practice.
So I've told you how I handle this
and so I recommend that you do something very similar.
One last thing about this rule is
this rule actually prohibits nurse practitioners
from owning pain management clinics.
So you should know that.
So other laws in the state of Texas
that affect our practice.
The Heath and Safety Code, Chapter 481
of the Texas Controlled Substance Act
was updated on September 1st in 2017.
House Bill 2561 was passed which amended this Act
and imposed more licensing board oversight
over the prescription of controlled substances.
This law now requires licensing boards to publish guidelines
on the responsible prescribing of opioids, benzodiazepines,
barbiturates, and that last medication
that honestly I cannot pronounce, so I'm not even gonna try.
The Board of Nursing is now required to monitor
the information in the Prescription Monitoring Program
that is set up and monitored by the Board of Pharmacy.
So they're required to look in there and to identify
any potentially harmful prescribing practices
and act accordingly.
So APRNs are now required to check
the Prescription Monitoring Program
prior to prescribing one of these categories of drugs,
unless the patient has cancer or is in hospice care.
Any prescriptions written for pain for a cancer patient
or a hospice patient
must clearly document on the prescription and record
that the patient has cancer or is receiving hospice care.
Violation of this is grounds for disciplinary action
in this rule.
One may not be held accountable
for not checking the prescription monitoring system
if they have made a good faith effort to do so
and were unable to check it
for reasons out of their control.
So if the website is down and you're seeing patients
and you've gone in to check it and you can't,
it's not gonna be up until tomorrow,
you just need to document that in your note and say,
I've tried, the website's down.
Unsure when it's coming back up.
That way, if anything happens,
you have that documentation to support you.
Case scenario.
You're an AG ACNP working as an intensivist.
You've been coding a patient for 30 minutes
without any response.
What two Texas laws gives us direction for this scenario
and based on Texas law,
how do you wanna handle this situation?
So the Advanced Directives Law
and the Death and Disposition of the Body
help give us direction in this scenario.
So the Advanced Directives Law specifically says
before withholding or withdrawing life-sustaining treatment
from a patient, now a code is considered
life-sustaining treatment.
So before stopping that, essentially,
or any life-sustaining treatment,
the attending physician must determine if the steps proposed
are lawful and are consistent
with the patient's existing desires.
So that means that in this scenario, in the state of Texas,
we cannot stop a code because a code is considered
life-sustaining treatment.
It requires the physician to make that determination
and to say stop the code.
So in this scenario, the ACNP needs to get a physician,
tell them what's going on and ask if they wanna continue
or do they wanna stop the code
and then document that conversation.
This is not a decision in Texas that we can make.
The Death and Disposition of the Body Law also says
if artificial means of support preclude a determination
that a person's spontaneous respiratory
and circulatory functions have ceased,
the person is dead when, in the announced opinion of
a physician, according to ordinary standards of
medical practice, there is irreversible cessation of
all spontaneous brain function.
Death occurs when the relevant functions cease.
So that statement in there is saying, again,
that we cannot pronounce death
when the patient is receiving artificial means of life.
It requires a physician to make that determination.
So, again, a code is considered artificial means of life
and in that scenario,
the physician has to make that decision.
The acute care NP cannot.
Or any NP cannot.
So you're an AG ACNP working for a hospitalist group.
One of the physicians asks you to write a DNR order
on a patient.
He also asks you to complete an out of hospital DNR order
in preparation for discharge.
Based on Texas law,
how do you want to handle this situation?
It is the Advanced Directives Law
which addresses this scenario.
And so the Advanced Directives Law,
which we just talked about,
prohibits nurse practitioners from writing
out of hospital DNR orders.
Additionally, it prohibits us from writing DNR orders,
whether they're in an inpatient or an outpatient setting.
So you should not write an out of hospital DNR order
and you should not write an inpatient DNR order.
The Board of Nursing, there's a new law
that goes into effect on April 1st in 2018,
that prohibits a non-physician provider
from writing any DNR order regardless of the setting.
And so even before this law went into effect
or goes into effect, the Board of Nursing's position on that
is what you see at the bottom of your screen here
and their position is that DNR or an out of hospital
do not resuscitate order, is a medical order
that must be given by a physician.
And that is not in the Nurse Practice Act.
It is not in the Board rules.
It is on their website under frequently asked questions
for the APRN.
But that tells us
what the Board of Nursing's position is on that.
So general provisions for the Do-Not-Resuscitate Orders.
I've really already addressed this.
This is part of the Advanced Directive Law
in a Subchapter E.
This law basically states that a physician must write
the DNR order regardless of where their patient is.
Whether it's an out of hospital DNR order
or whether it's an inpatient DNR order,
the physician must do it.
We are, however, responsible, as registered nurses
and advanced practice nurses,
to make sure that if we're caring for a patient
that has a DNR order on file,
that they are aware that they have a DNR order.
This was enacted mainly because there were people out there
making patient's DNRs
against the family or patient's wishes.
Now this law has gone into effect
to protect the patient's rights and the family's rights.
So still talking about this law,
prior to the DNR being ordered, the physician, PR or nurse
must inform the patient of the order
or if the patient is incompetent make a reasonable,
diligent effort to contact the medical power of attorney,
the legal guardian, attorney, or next of kin.
If a patient arrives with a DNR order
and tells the physician, nurse, PA
then they are responsible for notifying
the patient's agents.
So this is the notification portion of the law.
The physician may revoke the DNR
if the patient or the patient's agent revokes
an advanced directive,
the patient tells a person providing the care to revoke it.
The person is then required to notify the physician
and then the attending physician may revoke the DNR
at any time.
So this means that you, as an NP, cannot revoke the DNR,
say DC the DNR.
The physician has to do it.
When it comes to writing and discontinuing a DNR order,
the physician has to do it.
But we are responsible for notifying patients of the order.
So our case scenario.
You are an AGACNP working for a cardiology practice.
The office manager comes to you and says,
Mr XYZ passed away last night from cardiomyopathy.
His family needs the death certificate signed
as soon as possible for insurance reasons.
The office manager asks you to sign
because the cardiologist is out on vacation
for the next three weeks.
So let's see if this is within our scope of practice.
So what Texas law applies here,
and it's Death Records and this law requires
that the attending physician complete the death certificate
and sign it.
How should you handle this situation?
You cannot sign the death certificate.
NPs cannot sign death certificates in Texas.
However, there is an exception.
So as of May 27, a new law was passed, SB 919,
that expanded the signing of death certificates by APRNs.
This law allows APRNs or PA to sign death certificates
for patients receiving hospice or palliative care.
These certificates must be completed and signed
within five days.
So that is the only time that we can sign
a death certificate.
So you're an acute care NP working night shift
for a hospitalist service at the community hospital.
You provide cross coverage for the hospitalized patients
and do admissions at night.
You receive a call from the RN stating that Mr ABC,
who was a DNR, passed away,
and she would like you to come and pronounce the death.
So what laws applies and how should you handle this?
So the Death and Disposition of the Body Law
is the law that governs this.
So you can pronounce the death if they are not on
artificial life support of any kind.
So you have to ensure that there is
no artificial life support.
If there is you cannot pronounce the death.
And then you need to check the facility's policy.
Some facilities in Texas will allow you to do it
and some facilities will not allow you to pronounce.
So you have to know.
The facility where I work per diem does not allow us
to pronounce death so I cannot pronounce death.
Per Texas state law, it used to require two RNs
to pronounce death,
but that two RN requirement has gone away.
Now it can be pronounced under one RN but, again,
the institution must have a policy permitting that.
So you're an AGACNP working for a hospitalist service.
You're preparing to discharge a patient
who is wheelchair bound.
The patient asks you to sign a renewal application
for the handicap parking placard.
So this law is found in the
Transportation Code of Texas state law
and this law states that we, as NPs,
can only sign the initial certification
or the application for disability placard.
Renewals must be signed by the physician.
So this is not a scenario that we can do.
If it were the initial application, we could do it,
but otherwise we cannot do that.
I have seen this law over the years go from us
not being able to do it at all, to being able to do it
in rural areas as long as the area was 100 miles
or something outside from a metropolitan area.
It may have even been more than that,
to now we can do the initial certification but nothing else.
So I'm sure this law will evolve even more over time.
But if you're sitting there laughing to yourself thinking
this is utterly ridiculous, you're absolutely right.
I think the same thing most days.
But these laws are another really good example of
why we need to be involved politically at the state level
and federal level.
These are all state laws but our voice needs to be heard.
Our legislatures need to know who we are
and what we stand for and what our practice is
so that we can change these unnecessary requirements.
Another case scenario.
So you're an AG ACNP working with a hospitalist group.
Upon reviewing your patient load in the morning,
you notice that a 14 year old male has been admitted
to your service for an asthma exacerbation.
Does your scope of practice include
taking care of adolescents?
So this is debatable.
You wanna consider your scope of practice
and whether it really includes adolescent care.
I would venture to say that adolescent care
in a outpatient specialty practice might be within the
scope of practice of the Adult-Gerontology
Acute Care NP program.
The reason I say that is because you have had
adolescent content that is considered primary care
in the program.
So you could probably argue and argue successfully that
in the outpatient setting, in a subspecialty practice
that's within your scope of practice.
On the inpatient side I don't know that we could be
just as successful in arguing that.
But your national certification says ages 13 and over.
However, when I was at a national organization
nurse practitioner faculty two years ago,
no in 2017, when I was there in 2017,
I was listening to some of the national faculty
that put together the Adult-Gerontology Acute Care
competencies that were published in 2016.
They got up and said that
even though this certification says 13 and over,
that the scope of practice is really 18 and over.
That 13 and over is for that primary care
Adult-Gerontology nurse practitioner
and for the Adult-Gerontology Acute Care it's 18 and over.
So national standards are really saying 18 and over
for the acute care NP.
So I would stay away from anybody in your setting
that is less than 18 years old.
The Texas Board of Nursing doesn't have
a specific requirement but they will defer this to
what the national nursing policies and organizations say
as far as age limitations.
Let's look at our next case scenario.
An AGACNP colleague has just graduated with her DNP.
She tells you she plans to introduce herself as Doctor ABC
to her patients.
What Texas law governs the use of the term Doctor?
That is Occupational Code Title 2, Health Professions.
In this law it governs the use of Doctor.
So ultimately it says that she can do it
but there are qualifications.
She has to identify herself as a registered nurse.
She has to say what type of Advanced Practice Specialty
she is, and she has to identify the university
granting the academic doctoral degree
and that it was an academic degree and not a medical degree.
So this law can be kind of cumbersome.
I do not personally, do not use my term doctor
with my patients.
They already think I'm a doctor
and they already confuse me with a doctor.
Every time they call me doctor, I tell them,
no, I'm a nurse practitioner.
They say, yeah but you're still my doctor.
I say, no, I'm a nurse practitioner.
She's like, well I'm just gonna call you a doctor.
I said, but you have to know that I'm a nurse practitioner.
I correct 'em every time.
If they do it three or four times, I correct them every time
because of this law, one,
and regardless of which state you're in,
you are obligated to make sure that your patients know
exactly who you are and what your degree is.
So I don't use my doctor term,
the term doctor with my patients
'cause I don't want anybody, the patient or any colleagues,
to think that I am misrepresenting myself as a doctor.
I do not ever wanna be in that situation
and the safest thing for me to do is not refer to myself
as doctor in a clinical setting to patients.
So other common questions that I've been asked.
Can you work as an RN after you graduate?
Yes you can.
There's some misconceptions going around about this.
We've had a person,
I had a graduate a couple years ago that said that
her nurse manager told her that she can't work as an RN
after she graduates because if she had an emergency
and didn't intervene, as an advanced practice nurse,
she would be held liable
and the hospital would be held liable.
Well there's so much behind that
that prevents that from happening.
One, the Board of Nursing recognizes
that your RN scope of practice is separate from
the APRN scope of practice.
Two, in Texas, and in any state,
if you're working in the hospital as a registered nurse
and you want to work as an APRN,
you have to go through the credentialing process
and receive privileges to work as a nurse practitioner
in the hospital.
If you don't have privileges to work as
a nurse practitioner, you cannot do any
advanced practice nursing skills in that hospital.
So an RN that has just graduated
is not going to have privileges to do anything
at the advanced level in the hospital.
So she can't intervene by hospital by-laws.
The third factor is,
in Texas you have to have a supervising agreement.
That is not in effect in a person who's just graduated.
So you can't operate as an APRN.
So there's other factors that this nurse manager
probably did not really understand.
Those factors come into play.
So this could not be any further from the truth.
This student, when she asked me this scenario,
I told her these things that I just said
and she also emailed the Board of Nursing,
the Texas Board of Nursing.
And the Board of Nursing basically agreed with what I said
but they also said that you will always be held accountable
to your highest level of education.
So they said if something goes wrong
and she should have known that it was a bad thing
because of her APRN education,
even though she was not licensed or credentialed
at the hospital to function as an APRN,
she would still have to act at the nursing level
based on her APRN education.
So the example that they gave her was
there is a pediatric nurse practitioner
who was working in a public health clinic and did an exam,
a well baby exam, I believe, and found a click
when they did the hip abduction test, found a click.
That nurse did not report it to the appropriate physician
and she got sanctioned by the Board.
The Board's position was a registered nurse
without the PNP education would not necessarily have known
what that click was or what to do with it.
However, because that RN had a PNP education,
she knew what to do.
She knew what that meant and that she needed to act.
Even though she wasn't working as an NP
and didn't have the delegation collaboration agreement
established and she was only working as an RN,
because she had the education of the PNP
and was working as an RN, she had a higher obligation
than an RN that didn't have that education
and a higher duty to the baby
to report that to the physician.
Whereas an RN without that education
would not have been expected by the Board of Nursing
to report that.
So you will always be held
to your highest level of education
and that's important for you to know.
So can you work as a registered nurse
after you have an NP license?
If you choose to, yes.
You can absolutely do that.
If you wanna do that.
Personally, you're coming to an NP program
because you wanted something different.
You wanted a more challenge,
you wanted to expand your skills.
I'm not sure why anybody would want to work as an RN
and an NP.
It's very hard to cross those boundaries
and at this point, I don't think I could even
work at the bedside or as a RN anymore
because I just don't think in that same manner anymore.
So it would be very hard for me to float back and forth.
But you can.
My recommendation to anybody that does that
is make sure that you do it at two different facilities.
Otherwise if you do it at the same facility,
that is gonna be really, really dicey
and I don't recommend that.
So is giving medical advice to a family or friend
or to anyone you know, appropriate?
So the answer is no.
You really shouldn't give any medical advice
to anybody and you shouldn't prescribe to anybody
'cause you can be held legally accountable
and liable for that, especially if something goes wrong.
So you wanna make sure that you don't do that.
I've had students ask me for medical advice
and I always tell them I can't give you medical advice.
I think you need to go see your physician
and that's where I go.
So that's how you should approach things too.
You don't want to inappropriately prescribe for somebody
because if something goes wrong with that
you will be sanctioned by the Board.
If they sue you and they open an official lawsuit,
that's an automatic report to the Board of Nursing.
So you don't wanna take those chances.
So one last final word between a rock and a hard place
with a patient.
So, when you find yourself
in between a rock and a hard place,
regardless of which state you're in,
whether it's an independent practice state
or a supervisory state or a collaborating state,
you want to make sure that you understand this point.
In between a rock and a hard place.
And what do I mean by that?
I mean that if the required treatment for the diagnosis
is going to make the patient worse
and then not treating them
is going to make the patient worse,
you're in between a rock and a hard place.
Those decisions are not decisions that we make
as nurse practitioners.
Those are decisions that need to be made by the physician.
My best example that I can give you
is a Doctor Carter story.
So she told me a story one time about a patient
that she was called about from the Emergency Room.
She was on call, she was about to get off in the morning,
around seven o'clock in the morning.
She receives a call from the ICU, or from the ED.
She's doing ICU cross cover and the ED says,
I've got this 25 year old patient
who's come into the Emergency Room.
She's hypoxic.
We have her intubated.
She's on 100% FIO2.
She is still standing at 85%.
We can't get it up any more.
She has a massive PE.
She is slightly hypotensive.
Do you recommend giving TPA?
She said that she told the ED,
this sounds appropriate but why are you asking.
The ED said, she just had abdominal surgery
within less than a week.
So, as you know, TPA is going to cause her to bleed
and recent surgery is a contrary indication.
That is what I mean by a rock and a hard place.
She is going to die from that PE if we don't treat her
and she is likely to bleed out if we treat her with TPA.
Death between a rock and a hard place.
When you have a scenario like that,
that is not a decision that you make.
That is a decision for the physician to make.
Doctor Carter told me she referred that to the physician.
She called him and got him in to see the patient
and they made the decision.
Ultimately they decided to treat her.
Unfortunately the patient did bleed out and died.
But the patient was forcing their hands.
They really didn't have much of a choice.
So I'm not surprised in the story that she told me
that they decided to treat her.
They were obligated to treat her.
But in those type of situations, again,
the physician has to make those decisions,
regardless of what state you're in and what your laws say.
That needs to be a physician decision.
There needs to be an extensive conversation that is had
with the patient's family or the next of kin
or their legal guardian or whoever,
to let them know of the risk and benefits
of treating the patient in this situation
and the risk and benefits of not treating the patient
in this situation.
So there are scenarios that you'll come across
as a nurse practitioner in practice
that you need to be aware that you need to know
when to collaborate with your physician.
I will say for the acute care students, for you guys,
TPA, any time you need to order TPA,
you need to discuss that with the physician
and let the physician make that decision.
Some hospitals even say that
only the physician can make that decision.
So you have to be aware of those type of things.
All right.
That is the end of this lecture.
I hope that you have learned a lot.
I've really enjoyed giving this lecture, as I always do
and you have a wonderful day.
Feel free to email me if you have any questions.
Bye bye.
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