An official State of Texas website.
Revision 22-3; Effective Nov. 8, 2022
Contractors that provide clinical services must develop and maintain written clinical prescriptive authority agreements (PAAs), protocols and standing delegation orders (SDOs) in compliance with statutes and rules governing medical and nursing practice and consistent with national evidence-based clinical guidelines. When HHSC revises a policy, contractors need to incorporate the revised policy into their written procedures.
5310 Prescriptive Authority Agreements (PAAs)
Revision 22-3; Effective Nov. 8, 2022
Contractors who delegate the act of prescribing or ordering a drug or device to advanced practice registered nurse(s) and/or physician assistant(s) must have in place a prescriptive authority agreement (PAA), as required by Texas Administrative Code Title 22, Part 9, Chapter 193.
The PAA must meet all the requirements delineated in the Texas Medical Practice Act, Chapter 157 including, but not limited to, the following minimum criteria:
- Be in writing, signed and dated by the parties to the agreement.
- Include the name, address and professional license numbers of all parties to the agreement.
- State the nature of the practice, practice locations or practice settings.
- Identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed.
- Provide a general plan for addressing consultation and referral.
- Provide a plan for addressing patient emergencies.
- Describe the general process for communication and sharing of information between the physician and the advanced practice registered nurse or physician assistant to whom the physician has delegated prescriptive authority related to the care and treatment of patients.
If alternate physician supervision is used, designate one or more alternate physicians who may:
- provide appropriate supervision on a temporary basis in accordance with the requirements established by the prescriptive authority agreement and the requirements of this section;
- participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; and
- describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes the following:
- chart review, with the number of charts to be reviewed determined by the physician and advanced practice registered nurse or physician assistant; and
- periodic face-to-face meetings between the advanced practice registered nurse or physician assistant and the physician at a location determined by the physician and the advanced practice registered nurse or physician assistant.
5320 Protocols
Revision 22-3; Effective Nov. 8, 2022
Contractors that employ advanced practice nurses or physician assistants must have written protocols to delegate authorization to initiate medical aspects of client care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than have two documents, this delegation can now be included in a prescriptive authority agreement (PAA) if both parties agree. The PAA and protocols need not describe the exact steps that an advanced practice nurse or a physician assistant must take with respect to each specific condition, disease or symptom.
The protocols must be reviewed, agreed upon, signed, and dated by the supervising physician and the physician assistant or advanced practice nurse at least annually and maintained on-site.
5330 Standing Delegation Orders (SDOs)
Revision 22-3; Effective Nov. 8, 2022
When services are provided by unlicensed and licensed personnel, other than advanced practice nurses or physician assistants, whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written SDOs in place. SDOs are distinct from specific orders written for a particular individual. SDOs are instructions, orders, rules, regulations, or procedures that specify under what set of conditions and circumstances actions should be instituted. The SDOs delineate under what set of conditions and circumstances an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting and provide authority for use with individuals when a physician or advanced practice provider is not on the premises, or prior to being examined or evaluated by a physician or advanced practice provider.
Example: SDO for assessment of blood pressure or blood sugar which includes an RN, LVN or NLHP who will perform the task, the steps to complete the task, the normal and abnormal range, and the process of reporting abnormal values.
Other applicable SDOs when a physician is not present on-site may include, but are not limited to:
- obtaining a personal and medical history;
- performing an appropriate physical assessment and the recording of physical findings;
- initiating or performing laboratory procedures;
- administering or providing drugs ordered by voice communication with the authorizing physician;
- providing pre-signed prescriptions for:
- oral contraceptives;
- diaphragms;
- contraceptive creams and jellies;
- topical anti-infective for vaginal use;
- oral antiparasitic drugs for treatment of pinworms;
- topical antiparasitic drugs; or
- antibiotic drugs for treatment of STIs;
- handling medical emergencies, to include on-site management as well as possible transfer of the client;
- giving immunizations; or
- performing pregnancy testing.
The SDOs must be reviewed, signed and dated by the supervising physician who is responsible for the delivery of medical care covered by the orders and other appropriate staff at least annually and maintained on site.
5340 Resources
Revision 22-3; Effective Nov. 8, 2022
Requirements addressing scope of practice and delegation of medical and nursing acts can be accessed at the following websites:
Rules that are most pertinent to this topic are:
- Texas Administrative Code, Title 22, Part 9, Chapter 193
- Texas Administrative Code, Title 22, Part 11, Chapters 221 and 224
- Texas Administrative Code, Title 22, Part 9, Chapter 185 (Physician Assistant Scope of Practice)