Key Takeaways
- Texas does not allow nurse practitioners to practice independently.
APRNs need physician delegation for the medical aspects of patient care, and that delegation must be established in writing.
- A delegation protocol and a prescriptive authority agreement are not necessarily the same thing.
An APRN needs physician delegation for medical aspects of care, while prescribing or ordering drugs and devices requires delegated prescriptive authority.
- Texas has requirements for physician delegation and prescriptive authority.
How Do Collaborative Agreements Work for Texas Nurse Practitioners?
Texas takes a different approach to nurse practitioner practice than states that allow NPs to practice independently after meeting certain experience or credentialing requirements.
In Texas, an advanced practice registered nurse (APRN), including a nurse practitioner, may independently provide the nursing aspects of care within the APRN’s scope of practice. However, medical aspects of care require physician delegation.
For Texas NPs, the questions are what authority a collaborative agreement provides, what activities are being delegated, and whether additional requirements apply to prescribing.
What Is a Physician Delegation Protocol in Texas?
A delegation protocol establishes the authority for an APRN to perform medical aspects of care under physician delegation.
Texas Board of Nursing guidance states that APRNs practicing in Texas must have a relationship and practice agreement with a Texas-licensed physician for medical aspects of patient care. The written delegation mechanism must be signed and reviewed at least annually.
The agreement should reflect the actual practice rather than functioning as a generic document. For example, the medical aspects of care being delegated may include:
- Formulating medical diagnoses
- Creating medical plans of care
- Ordering laboratory or diagnostic tests
- Making certain medical determinations
- Ordering or prescribing drugs and medical devices
The NP remains professionally accountable for the advanced practice nursing care they provide. Physician delegation does not transfer that professional responsibility to the physician.
For an NP opening or purchasing a practice, this delegation arrangement is a central part of the practice’s legal structure.
Is a Delegation Protocol the Same as a Prescriptive Authority Agreement?
No. This is one of the most important distinctions for Texas nurse practitioners.
The general delegation protocol addresses the APRN’s authority to provide medical aspects of care. Prescriptive authority is a separate form of delegated authority. If an NP will prescribe or order drugs or medical devices, the NP must have the appropriate prescriptive authority and physician delegation. That delegation must be addressed through a prescriptive authority agreement or, when applicable, a facility-based protocol.
The two arrangements can be incorporated into the same document. The Texas Medical Board explains that delegation protocols can be included within a prescriptive authority agreement rather than in separate documents.
But combining the documents does not eliminate the distinction between the two types of authority.
Keep this distinction in mind when reviewing an agreement for a new NP practice. The document should clearly establish the authority the physician is delegating and comply with the requirements that apply to that delegation.
If you are a Texas nurse practitioner reviewing a collaborative or delegation agreement, Jackson LLP can review the arrangement and identify the legal requirements that apply to your practice and prescriptive authority. Book your complimentary consultation with our team today.
What Must a Texas Prescriptive Authority Agreement Include?
Texas law establishes minimum requirements for prescriptive authority agreements.
For agreements entered into on or after September 1, 2019, the agreement must be in writing and reviewed, signed, and dated annually by the parties. It must identify the parties and their professional license numbers, describe the practice and practice locations, and list the categories of drugs or devices that may or may not be prescribed.
The agreement must also address consultation and referral, patient emergencies, and communication and information sharing between the physician and APRN.
If the practice uses alternate physician supervision, the agreement must identify the alternate physician or physicians. The agreement must also include a prescriptive authority quality assurance and improvement plan that addresses chart review and periodic meetings.
Together, these requirements establish the framework under which the NP exercises delegated prescriptive authority.
How Often Must Texas NPs and Delegating Physicians Meet?
For prescriptive authority agreements entered into on or after September 1, 2019, the parties must meet at least once each month. The meetings must address patient care improvement, information about patient treatment and care, needed changes in patient care plans, and referral issues. The meetings must also be documented.
The quality assurance and improvement plan must also address chart review. Texas does not establish a single required number or percentage of charts that must be reviewed. Instead, the parties determine the number based on factors such as experience, the length of the working relationship, practice setting, and patient needs.
These requirements carry added weight for an NP operating at a separate location from the delegating physician.
The Texas Medical Board states that there is no specific mileage requirement between the physician’s and APRN’s practice locations. However, the physician must provide adequate supervision, and the distance between locations may affect whether that supervision is adequate.
Does the Texas Medical Board Need to Know About the Delegation?
Yes, when prescriptive authority is being delegated.
Texas requires physicians who delegate prescriptive authority to APRNs to register that delegation with the Texas Medical Board (TMB). Physicians use the TMB’s online system to register prescriptive authority delegation, and they generally should report changes to supervision or delegation within 30 days.
Registration is a compliance obligation separate from signing the agreement.
The APRN and physician also need to make sure the underlying licenses meet the requirements for delegation. The Texas Medical Board requires an active, unrestricted Texas nursing license for an APRN to use the online registration system.
For an NP establishing a new practice, the delegation agreement, prescriptive authority, and registration requirements should therefore be addressed together.
What Should Texas Nurse Practitioners Review Before Signing an Agreement?
A Texas NP should understand exactly what the physician is delegating before signing a collaborative or prescriptive authority agreement.
Start by identifying the medical services the NP will provide. Then determine whether those activities require physician delegation and whether prescribing or ordering drugs or devices will require a separate prescriptive authority arrangement.
The NP should also review the agreement’s provisions concerning practice locations, consultation, referrals, emergencies, communication, chart review, quality assurance, meetings, alternate physicians, and termination.
If the NP is employed by a medical practice, the employment agreement also warrants a separate review. Employment terms can create obligations that go beyond the physician delegation relationship.
Finally, practice owners should make sure their agreements match the way the practice operates. A delegation arrangement drafted for one location or type of practice may not be appropriate after the NP opens another location, changes ownership, adds services, or changes the physician relationship.
How Our Texas Healthcare Attorneys Can Help You
Texas nurse practitioners do not have to figure out these requirements alone. Jackson LLP works with nurse practitioners and other advanced practice professionals on collaborative agreements, physician delegation, prescriptive authority, practice formation, and other legal issues affecting independent healthcare practices.
Schedule your free consultation with a member of our team today.
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Frequently Asked Questions About Texas Nurse Practitioner Collaborative Agreements
Do Texas nurse practitioners need collaborative agreements?
Yes. Texas APRNs need a collaborative relationship and a written physician delegation mechanism for the medical aspects of patient care. Texas is not a full-practice-authority state, so nurse practitioners do not have the same independent practice authority available to NPs in some other states.
Is a Texas delegation protocol the same as a prescriptive authority agreement?
No. A delegation protocol or practice agreement establishes physician delegation for medical aspects of care. A prescriptive authority agreement specifically addresses delegated authority to prescribe or order drugs and medical devices. The two may be incorporated into the same document when appropriate.
How often must a Texas NP and delegating physician meet?
For prescriptive authority agreements entered into on or after September 1, 2019, the parties must meet at least monthly. The meetings must be documented and address patient care improvement, treatment and care information, needed changes in patient care plans, and referral issues.
Does a Texas physician have to be physically present when an NP is practicing?
Not always. Texas does not impose a specific mileage requirement between the delegating physician and the APRN’s practice location. However, the physician must provide adequate supervision, and the circumstances of the arrangement can affect whether that requirement is satisfied.
Does a Texas NP need a prescriptive authority agreement to prescribe medications?
An NP who prescribes or orders drugs or medical devices must have appropriate prescriptive authority and physician delegation. The delegation must be established through a prescriptive authority agreement or applicable facility-based protocol.
Can a Texas NP have more than one delegating physician?
Yes. The Texas Medical Board states that there is no limit on the number of physicians who may delegate prescriptive authority to an APRN if all applicable requirements are satisfied.
