Quick Facts for APRN Practice in Texas

APRNs will have two license numbers one for RN and second for APRN. Both must be current to practice. Must have a valid RN license to get APRN license (or privilege to practice as RN thru Nurse Licensure Compact). For APRNS with more than one title as APRN (CNS and NP for example) must apply and be licensed in both specialties to use title but all APRN titles/license will be linked to a single APRN license number. APRN license can be verified online with either RN or APRN license number
New certificate with new license number will be sent following the APRN’s next renewal of license
Identification.
APRN, APN are not designated titles and should not be used as part of the APRN’s credentials at this time. BON is planning to update rules to allow use of “APRN” to denote licensure. Until the rule is changed APRNs must use RN to denote licensure and then advanced practice role and population-focus as the designated advanced practice title, PNP, FNP, CRNA, ACNS, etc…
Previous umbrella term in statute was Advanced Practice Nurse. In 2008 BON started changing rules to term APRN and as of 11/1/13 Advanced Practice Registered Nurses was enacted in statute (section 301.152, Texas Occupations Code). The definition reads:
“Advanced practice registered nurse” means a registered nurse licensed by the board to practice as an advanced practice registered nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialists. The term is synonymous with “advanced nurse practitioner” and “advanced practice nurse”
§221.11. When providing advanced practice nursing care to patients, the advanced practice nurse shall wear clear identification which indicates the individual is a registered nurse with the appropriate advanced practice designation authorized by the board.
§ 221.2(b) A registered nurse who holds current authorization to practice as an advanced practice nurse issued by the board in any of the categories indicated in the previous subsection shall use that title when functioning in the advanced practice role. A registered nurse who was granted authorization to practice in an advanced role and specialty not indicated in the previous subsection prior to January 1, 2006, may continue to use the advanced practice title approved by the Board provided all requirements for maintenance of advanced practice authorization are met. "Advanced practice nurse" shall not be used as a title.
Continuing Education Requirements
Senate Bill 1058 requires nurses to complete 2 contact hours in nursing jurisprudence and ethics prior to every 3rd licensure renewal cycle (2 hours every 6 years). May not be met through an approved national certification. Content must include TX Nurse Practice Act, TX BON rules including Board Rule 217.11, standards of nursing practice, Texas BON position statements, principles of nursing ethics and professional boundaries
BON has 2 continuing education offerings which meet this requirement. Workshop titled “Protecting Your Patients and Your practice” and interactive online CNE Opportunity titled “Nursing Regulations for Safe Practice”.
Online course may be found at
Nurses who provide care to older patients (not defined) must complete 2 contact hours related to older adult or geriatric care every renewal cycle. Content must include elder abuse, age related memory changes and disease processes and end of life issues. National nursing geriatric certification satisfies this requirement.
Any nurse who performs forensic examination on a sexual assault survivor in any practice setting must have basic forensic evidence collection training or equivalent education before performing exam. ED nurses must complete 2 contact hours related to forensic evidence collection within 2 years of initial date of employment. One time requirement.
Every 2 year renewal cycle must complete 20 CE hours or proof of national certification
APRNs with prescriptive authority must have 15 CEs in pharmacotherapeutics
APRNs with controlled substance privileges must get an additional 3 CEs related to CS.
1 contact hour = 1 category CME. One semester credit = 15 CE hours (nursing relevant)
CE program must be approved by one of BON recognized CE accrediting agencies. Following are recognized agencies applicable to APRN practice
American Association of Nurse Practitioners
ANA/ANCC
AACN
American Association of Nurse Anesthetists
American College of Nurse-Midwives
Category 1 CME
Colleges and Universities
Other State Boards of Nursing
Required to keep record of CE for minimum of 2 renewal periods (4 years) in case of audit
Prescriptive authority
SB406 – removed some restrictions (not really effecting facility based), provided clarification in terminology such as what constitutes facility based, also made some things that have always been rules/regulations more obvious
Ex: clarified that prescriptive authority includes authority to order drugs and medical devices
Prescriptive authority is required to order durable medical equipment (DME)
Must keep certain permanent records at practice and retain records for 2 years after termination of agreement. Recommended to keep all documentation related to delegation (including agreements, quality meetings, etc.) for these length of time
One or more alternate physicians may be designated in PAA/protocol to assume quality assurance and consultation duties when the delegating physician is out of town or otherwise unavailable. This is not required. Designated physicians are not required to register with TMB or sign PAA/protocol.
PAA/protocols do not need to describe exact steps that APRN must take and should be written so APRN may use education and judgment in order to provide care for patients
APRN protocol is not to be confused with protocols that are used to describe specific steps to treat patients with certain S&S or undergoing a particular procedure
Current law does not technically require APRNs to have a delegating physician who is appropriate for all the patients the APRN sees in their practice. However, APRN is expected to create a safe environment and legally and ethically obligated to ensure that a mechanism for consultation and referral exists. This can be done by finding one or more physicians who are willing to consult the APRN regarding those patients outside the delegating physician’s scope. Advisable to get some type of written agreement with physicians who agree to consult and refer, delegation of prescriptive authority agreement is even better.
If one of the individuals in the PAA/protocol becomes the subject of an investigation by respective licensing board, the individual shall immediately notify the other party
Prior to executing PAA all parties must disclose any prior disciplinary action taken by their respective licensing board
QAI can include adding APRNs to all already existing QAI process for physicians.
PAA or protocol: Okay to say APRN may prescribe/order all dangerous drugs. If a list of drugs allowed to prescribe is included then it must include limitations on number of dosages units, refills permitted and instructions to be given to the patient for follow-up monitoring. An exclusionary list only requires listing of drugs not to be ordered or prescribed.
Prescriptions
Delegating physician is responsible for devising and enforcing a system to account for and monitor the issuance of prescriptions under the physician’s supervision
§222.4. Minimum Standards for Prescribing or Ordering Drugs and Devices.
(a) The APRN with full licensure and a valid prescription authorization number shall:
(1) order or prescribe only those drugs or devices that are:
(A) authorized by a prescriptive authority agreement or, if practicing in a facility-based practice, authorized by either a prescriptive authority agreement or protocols or other written authorization; and
(B) ordered or prescribed for patient populations within the accepted scope of professional practice for the APRN’s license; and
(2) comply with the requirements for chart reviews specified in the prescriptive authority agreement and periodic face to face meetings set forth in the prescriptive authority agreement; or
(3) comply with the requirements set forth in protocols or other written authorization if ordering or prescribing drugs or devices under facility-based protocols or other written authorization.
(b) Prescription Information. The format and essential elements of a prescription drug order shall comply with the requirements of the Texas State Board of Pharmacy. The following information must be provided on each prescription:
(1) the patient’s name and address;
(2) the name, strength, and quantity of the drug to be dispensed;
(3) directions to the patient regarding taking of the drug and the dosage;
(4) the intended use of the drug, if appropriate;
(5) the name, address, and telephone number of the physician with whom the APRN has prescriptive authority agreement or facility-based protocols or other written authorization;
(6) address and telephone number of the site at which the prescription drug order was issued;
(7) the date of issuance;
(8) the number of refills permitted;
(9) the name, prescription authorization number, and original signature of the APRN who authorized the prescription drug order; and
(10) the United States Drug Enforcement Administration numbers of the APRN and the delegating physician,if the prescription drug order is for a controlled substance.
APRNs do not have the authority to delegate an agent to orally communicate prescriptions to pharmacy for APRN. (may not delegate something this is delegated to you)
May be done if delegating physician designates one or more LVN/RN to perform this task.
RN/LVNs permitted to call prescriptions to the pharmacy must be designated in the practice protocol or in written document that is maintained on site. This must be made available to any pharmacist that requests the name(s).
This should only be used as a last resort
Controlled substance
Control substances limitations
Limit quantity to 90 day supply or refills totaling a 90-day supply
Consult with physician and note the consultation in the chart prior to:
Refilling the controlled substance (additional prescription for the same controlled substance for same individual)
Prescribing a controlled substance for any child less than 2 years of age
Schedule II
APRNs have been able to order schedule II drugs on hospitalized inpatients under a “standing medical order”. SB 406 allows physicians to delegate “order and prescribing” of schedule II drugs if allowed by facility medical staff bylaws and policies for facility based and hospice APRNs only. Non-facility based must continue to use SDMO and can’t write a prescription for discharge (Woolbert, pg 102).
Prescription may not be called to a pharmacy
Must be written on official prescription
Quantity must be written using both the numerical and written number
For more information and to order official pads:
If either your DPS or DEA is expired you can’t prescribe controlled substances till renewal is completed
DPS
Must be licensed by BON prior to applying for DPS
Prior to registering for DPS your supervising/delegating physician must be listed with the Texas Medical Board as giving you prescriptive authority for controlled substances.
For forms such as application or modification of registration:
Must update if change practice site and/or delegating physician. Complete and submit Modification of Registration PA/APN form.
Each physician delegating controlled substances must sign all forms and be registered with TMB. This includes renewals.
DEA
Must have DPS prior to submitting application for DEA
Inform DEA of change in status including name, address or schedules of APRN.
DOES NOT require notification regarding change in delegating physician
Application/renewal/change can be done online:
For changes go under registration tools, link “registration changes”
Drug Samples
APRN may sign for and distribute samples if:
Met all requirement to sign prescription drug orders (including having delegation written in PAA or protocol)
Samples are only for drugs APRN is eligible to prescribe
Record of sample is maintained and samples are labeled as specified in dangerous drug act or controlled substances act
Must keep record of obtaining and distrusting samples. Must maintain record of names of drugs and lot numbers for at least 2 years. Notation must be made in each patient’s chart when a sample is distributed.
Gold standard – keep log of all drugs distributed to include name of the patient, drug, lot number and date given. This allows easy access to list of patients who received a drug sample should that medication be recalled
Drugs must be properly labeled to include patient’s name, instructions for taking the medication including dosage, frequency and duration of treatment
NP and CNS Practice Issues
Law prevents APRNs and PAs from participating in the care of other’s physician’s patients without prior consent of those physicians. Usually, this prior consent is accomplished by asking physicians to sign a statement acknowledging the physician understands that APRNs assist in medical management and grants permission for any APRN assigned to the hospital service to participate in the care of patients the physician admits. Physicians routinely sign these statements when the physician applies or re-applies for privileges.
APRNs educated in primary care may care for hospitalized patients that are stable and not critically ill. These APRNs are not confined to ambulatory care settings by the BON.
Recommended only APRNs educated in acute or critical care work in intensive care settings
APRNs may not certify (re-certify) a terminal illness but may act as attending practitioner if hospice patient selects aNP to act in that capacity. Unfortunately federal legislation that enabled the change to the CMS rules to allow this specified NPS and did not include CNSs.
APRNs may declare death (as can any RN) but only a physician can sign a death certificate. May not declare death if resuscitation has been initiated or the patient is on artificial life support
Physicians may not jointly own a practice with an APRN
In advertising their services to the public, APRNS must avoid any reference to “medicine” or “medical practice”
CNS role vs NP role
Should CNS graduates seek APRN authorization from the BON?
Some CNSs in the traditional role are not sure if should bother going through the process of being authorized as CNS by BON. If the CNS graduate does not obtain authorization to work in CNS role that nurse cannot claim to be or use any title indicating that the nurse is a CNS when working in a clinical role. This prohibition includes using national certification titles that indicated advance practice status, such as ACNS-BC even if certified by ANCC. The CNS would still be able to use masters or doctoral degree as a credential.
Not being recognized as CNS by BON may make it more difficult to find job advertised for CNS
The traditional CNS role focuses on improving nursing care for a population of patients. Originally the role did not involve medical aspects of care and the CNS improved nursing through assessment, consultation, research and teaching. CNSs analyze systems to obtain optimal results. A growing percentage of CNSs treat individual patients and have prescriptive authority and are educated to diagnose, treat and prescribe for patients within their specialty. CNSs apply their traditional skills to improve the medical aspects care they provide. CNS education includes both acute and primary care settings
NP role focuses on managing the treatment for individual patients within a specific population of patients
Role analysis of Psychiatric Mental Health NPs and CNSs and Gerontological CNSs and NPs show they have identical functions and perform the same jobs
There is an overlap in the role of the CNS and NP. This often creates confusion in determining if the job requires a CNS or NP. NPs may be hired to meet some patient care goals that are more commonly associated with the CNS role and CNSs with prescriptive authority may be hired to manage medical aspects of care for individual patients, a role more commonly assumed by NPs
Typically an NP is hired if medical management is the major need of the position and a CNS is hired if the employer needs an APRN who can improve nursing care and bring a team of interdisciplinary providers together to work as a team
Scope of Practice
Physician scope is unlimited and their delegated authority is broad often resulting the physician trying to delegate care that is beyond the APRN’s scope. A physician can delegate any care they think an individual is competent to perform. Physicians often fail to understand other practitioners must function within the limits of their license. For example a women health NP who works for family physician may only care for women and may not provide primary care to children or men.
An APRN is not able to accept a delegation that is outside his/her scope of practice
Diagnosing and prescribing are in the APRNs scope of practice (otherwise APRN would not be able to accept the delegation) but in the State of Texas these acts are not performed independently. Delegation must be thru a PAA or protocol.
Other aspects of care most APRNs provide are typically considered as nursing acts
Expand scope to include new procedures/activities.
BON posted guidelines for Determining Scope of Practice with FAQs
This more of an issue than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology, indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. Must learn to respond and manage adverse reactions/complication that may occur. In many cases, on the job training will not include this type of content. Need to be able to provide evidence of education/training and documentation of competence
APRN Delegating to Unlicensed Personnel
Unlike a physician, an APRN’s ability to delegate to unlicensed personnel is limited, it is the same as that of an RN
BON Position statement 15.18 permits RNs and LVNs to take orders from APRNs. Physician is not required to be physically present at the location where APRN provides care. The order is not required to be countersigned by the physician.
APRN may order orthotics and prosthetics but need be delegated by physician in PAA or protocol
BON views ordering DME and medical supplies in the scope of practice of APRNs. The difficulties are caused by reimbursement issues created by federal and state regulations. ACA makes it clear that NP and CNSs may order DMEs but requires the physician to co-sign documentation verifying the face-to-face evaluation occurred.
Federal law currently states that only physician may order home health services (regardless of payer). This is why home health agencies that are Medicare-certified cannot accept orders or plan of care for home health from an APRN.
APRNs may not order restraints for behavioral reasons. May do so for medical purposes if permitted by facility bylawas
Federal regulations are silent about whether or not APRNs can sign paper work or order DNR status. It is within the APRN’s scope. Texas law specifies a physician must note the patient’s wish not be resuscitated, consequently APRNs should not sign DNR orders or “out of hospital DNR” form.
May write verbal order for DNR at direction of an attending physician who witnessed the patient’s statement
APRN can complete the required documentation related to DNR order if the APRN discussed the patient’s wished with pt/family. DNR orders need to be accompanied by the following documentation:
Persons whom APRN spoke and if not patient, why and relationship to the patient
Summary of the discussion
Decision reached
Apply to be Medicare Provider (only need if going to bill Medicare for services)
Novitas Solutions Website:
Novitas is the Medicare Administrative Contractor for the region in which Texas resides
National Provider Identifier (NPI):

Texas Board of Nursing.(2014). Board to issue advance practice registered nurses a second license number.Texas Board of Nursing Bulletin, 45(1), 1.