Texas Nurse Practitioner Common SOP Scenarios

Nurse Practitioner Scope of Practice: Texas Specific Commonly Asked Questions

The questions below are answered based on national nursing organizations’ definitions of nurse practitioner scope of practice, the Texas Board of Nursing nurse practice act, rules and regulations, and Texas laws which mandate what nurse practitioners may or may not do. The answers presented below are considered expert opinion and do not represent legal advice. They do not represent the Texas Board of Nursing’s position. The Texas Board of Nursing is the authority on the practice of nursing in Texas and anyone seeking their official position or clarification on requirements regarding a scenario should check with the Texas Board of Nursing and/or seek official legal assistance. The answers below are provided for educational purposes only and may change without prior notice. It is the responsibility of every nurse practitioner to remain updated in their knowledge of scope of practice.

Can a Nurse Practitioner in Texas Do : Scenario 1

Can a family nurse practitioner, in Texas, serve as a first assistant in surgery and complete closures?
Texas Board of Nursing Rule 217.18 Assisting at Surgery addresses this question. This rule requires that any registered nurse that wishes to perform the function of first assistant (RNFA) meet all the following criteria.
1. Have a current Texas registered nurse license.
2. Successfully complete a nurse first assistant educational program. The program must be approved or recognized by the Texas Board of Nursing.
3. Meet one of the following.
a. Certified in perioperative nursing by an organization recognized by the board of nursing.
b. Be a currently licensed APRN and qualified by education, training, or experience to perform perioperative nursing.
Provided that the family nurse practitioner meets all the criteria above they may function as a first assistant in Texas. The issue that the family nurse practitioner faces, is that their APRN education, does not prepare them for perioperative nursing care. To meet criteria 3 above, they would have to be certified in perioperative nursing by an organization recognized by the board or be able to show solid documentation that they have the experience, education, or training in perioperative care. Anyone who has questions about the qualifications and if they meet should contact the Texas Board of Nursing directly.

Can a Nurse Practitioner in Texas Do : Scenario 2

Can a nurse practitioner, in Texas, delegate the administration of medications, such as Tylenol or a Rocephin injection to a medical assistant?
All registered nurses, including APRNs, are obligated to follow all aspects of the nurse practice act and all Texas Board of Nursing Rules and Regulations. Texas Board of Nursing, Rules and Regulations, Chapter 224, Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments, is the governing rule that addresses this scenario.
According to Chapter 224.1 Application of Chapter, the rule applies to any patient that has a condition that is unstable or unpredictable. Furthermore, it applies to all of the following settings.
1. Hospitals
2. Rehabilitation centers
3. Skill nursing facilities Clinics
4. Correctional health
5. Private practice physician offices
6. Settings that do not otherwise meet the definition of independent living environment.
Chapter 224, describes the responsibility and accountability of the RN in delegating to unlicensed personnel, what tasks are appropriate to be delegated, what may not be delegated by the RN and criteria for delegation. According to Rule 224.8 Delegation of Tasks the administration of medication is a function of the registered nurse and may not be delegated to an unlicensed person, such as a medical assistant. Doing otherwise is violation of this rule and could cause an APRN to be disciplined by the Texas Board of Nursing.
This is most problematic in the clinic setting. Often, medical assistants are employed to help in the back office. Since they do not hold a license, APRNs are not able to delegate the administration of medication to them.
To remain compliant with this rule there are three options the APRN may use.
1. Work with/hire a licensed vocational nurse. The administration of some medications may be delegated to an LVN as this is within their scope or practice and license.
2. The APRN may choose to administer the medication themselves.
3. Work with the office and delegating physician to do the following.
a. Have the supervising physician be the one that is responsible for delegating this task
b. Document that the supervising physician (name and license number) is delegating the administration of medications to the medical assistant, in an office policy or in the APRN’s prescribe authority agreement.
c.The APRN must validate the medical assistant’s education. It is best to keep a record of this.
d. The APRN must validate that the medical assistant can safely perform medication administration. It is best to keep a record of this validation.
e. The APRN must adequately supervise the medical assistant. It is best to intermittently assess the medical assistant’s competency and keep documentation of such.
f. The APRN is required to intervene to ensure that the patient is safe, should they observe that the medical assistant is causing harm while performing the task. Should this occur they are responsible for letting the physician who is delegating the task know of their observations.
Please see the Texas Board of Nursing Rules, Chapter 224 for more information.

Can a Nurse Practitioner in Texas Do : Scenario 3

Can an acute care nurse practitioner in Texas, who is coding a patient, make the decision to stop the code if the patient is not responding?
Texas Health and Safety Code, Title 8, Subtitle A, Chapter 671 Determination of Death, contains language that prohibits any APRN from making the decision to call a code.
Chapter 671 Determination of Death, requires a physician to pronounce death when one is receiving artificial means of life support. It also requires death to be pronounced prior to terminating artificial means of life support. An APRN may not pronounce death when artificial means of life support is being administered, therefore, in the above scenario the nurse practitioner may not make the decision to call the code. Making the decision to call the code requires the pronouncement of death in a person who is receiving artificial life support and according to Texas law this may only be done by a physician.

Can a Nurse Practitioner in Texas Do : Scenario 4

Can a nurse practitioner in Texas, sign an out of hospital DNR order or an inpatient DNR order?
Texas Health and Safety Code, Title 2, Subtitle H, Chapter 166 Advanced Directives, prohibits any APRN from signing an out of hospital DNR order or an inpatient DNR order. According to this law, these orders must be signed by a physician. In regard to inpatient DNR orders, should the patient or their “agent” request the DNR to be rescinded, the physician must rescind the order.

Can a Nurse Practitioner in Texas Do : Scenario 5

Can a nurse practitioner in Texas treat acute pain via a telemedicine visit?
Texas Board of Nursing Rule 217.24 Telemedicine Medical Service Prescriptions allows for the treatment of acute pain unless prohibited by other laws. APRNs are reminded that they must comply with all aspects of Rule 217.24 and that Texas Board of Nursing Rule228.1 Pain Management regardless of the setting.
The Texas Controlled Substance act only permits licensed practitioners to prescribe a maximum of 10 days of opioids for the treatment of acute pain and prohibits one from writing a refill. Should a patient need opioid therapy beyond the 10 days, it is best to see the patient in person prior to issuing another prescription. Additionally, prescriptions for scheduled medications must be electronically sent to the pharmacy unless one has a waiver, from the Texas Board of Nursing, to use a paper- based prescription.
The Drug Enforcement Agency has requirements regarding telemedicine visits and the prescription of scheduled medications that must be followed. At the time that this was written, the requirements are in flux and are expected to change. Please check with our local DEA office on the current requirements.

Can a Nurse Practitioner in Texas Do : Scenario 6

My supervising physician lives in a different city than I do. Is it appropriate to conduct our monthly meetings via face time or video chat?
Texas Board of Nursing Rule 222.5 Prescriptive Authority Agreement, requires APRNs to meet with their supervising physician on a monthly basis to discuss patient charts. These meetings must include information related to the patient treatment and care, needed changes in patient care plans and issues relating to referrals. These meetings may take place in a manner that is mutually agreeable to by the APRN and physician. This means they may be conducted via telephone, video conference, or in person.