FLORIDA - PHYSICIAN AIDES, PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS (Scope of Duties)

I. UNLICENSED PHYSICIAN AIDES

1. What tasks may a physician direct his or her unlicensed employee to administer?

Under the direct supervision and responsibility of a licensed physician, a medical assistant may undertake the following duties:

1. aseptic procedures;

2. taking vital signs.

3. preparing patients for the physician's care.

4. performing venipunctures and nonintravenous injections.

5. observing and reporting patients' signs or symptoms.

B. Administering basic first aid.

C. Assisting with patient examinations or treatments.

D. Operating office medical equipment.

E. Collecting routine laboratory specimens as directed by the physician.

F. Administering medication as directed by the physician.

G. Performing basic laboratory procedures.

H. Performing office procedures including all general administrative duties required by the physician.

I. Performing dialysis procedures, including home dialysis.

F.S.A. § 458.3485

J. An unlicensed nurse's assistant may administer topical ointments and creams, eye, ear or nasal medications, and rectal or vaginal suppositories, ointments, and creams as a purely ministerial function provided that such activity by an unlicensed nurse's assistant in the administration of medication of any description is performed under the direct supervision of a registered professional nurse.

Op.Atty.Gen., 081-59, Aug. 11, 1981

2. Are there any circumstances when a physician may bill for the services rendered by an unlicensed medical assistant?

Yes. Physical therapy that unlicensed medical assistants perform on an insured, including application of hot packs, electrical muscle stimulators, ultrasound therapy devices, and mechanical massage, are incidental to the lawful practice of physical therapy, for purposes of qualifying for payment, by an automobile insurer, of assigned personal injury protection (PIP) benefits.

F.S.A.§ 486.021 (11); F.S.A. § 458.3485 2; F.S.A. § 627.736(5)(a)

II. LICENSED PHYSICIAN ASSISTANTS

1. What qualifications must an assistant have to be licensed as a physician assistant?

The State Board of Medicine (Board) will issue a physician assistant license to an applicant if the applicant:

A. Is at least 18 years of age;

B. Has satisfactorily passed a proficiency examination by an acceptable score established by the National Commission on Certification of Physician Assistants.

If an applicant does not hold a current certificate issued by the National Commission on Certification of Physician Assistants and has not actively practiced as a physician assistant within the immediately preceding 4 years, the applicant must retake and successfully complete the entry-level examination of the National Commission on Certification of Physician Assistants to be eligible for licensure; and

C. Has completed an application form and remitted an application fee not to exceed $300 as set by the boards.

F.S.A. § 458.347

2. Who may employ a physician assistant?

A physician assistant may be employed by a physician, a health care facility or institution.

3. What regulations must the employer of a physician assistant follow?

A. A supervising physician may delegate only tasks and procedures to the physician assistant which are tasks and procedures which the supervising physician is qualified by training or experience to perform. The decision to permit the physician assistant to perform a task or procedure under direct or indirect supervision is made by the supervising physician based on reasonable medical judgment regarding the probability of morbidity and mortality to the patient. Furthermore, the supervising physician must be certain that the physician assistant is knowledgeable and skilled in performing the tasks and procedures assigned.

B. The following duties are not permitted to be performed under indirect supervision (i.e where the supervising physician is not on the premises such that he or she is immediately available):

1. Routine insertion of chest tubes and removal of pacer wires or left atrial monitoring lines.

2. Performance of cardiac stress testing.

3. Routine insertion of central venous catheters.

4. Injection of intrathecal medication without prior approval of the supervising physician.

5. Interpretation of laboratory tests, X-ray studies and EKG's without the supervising physician interpretation and final review.

6. Administration of general, spinal, and epidural anesthetics; this may be performed under direct supervision only by physician assistants who graduated from Board-approved programs for the education of anesthesiology assistants.

64 FL ADC 64B8-30.012

C. The supervising physician of any physician assistant who is terminated from employment or otherwise ends employment as a physician assistant shall notify the Board's Council on Physicians Assistants in writing within 30 days of such occurrence.

64 FL ADC 64B8-30.004

D. If a supervising physician is unable to supervise his or her physician assistant, he or she will need to secure an alternate supervising physician with easy availability and the ability to communicate by way of telecommunication.

4. Are there any special rules relating to co-signing of charts by physicians?

A. During the initial six (6) months of supervision of each physician assistant all documentation by the physician assistant in a medical chart must be reviewed, signed and dated by a supervising physician within seven (7) days. Subsequent thereto, a supervising physician must review, sign and date all documentation by a physician assistant in medical charts within thirty (30) days.

Rule 64B8-30.012

B. A physician who supervises a physician assistant at a medical office other than the physician's primary practice location, where the physician assistant is not under the onsite supervision of a supervising physician and the services offered at the office are primarily dermatologic or skin care services, which include aesthetic skin care services other than plastic surgery, is not be required to review and cosign charts or medical records prepared by such physician assistant.

F.S.A. § 458.348

5. Is there a requirement for a patient to be seen by a physician on initial evaluation or consultation?

No. But as of July 1, 2006, upon initial referral of a patient by another practitioner, the physician receiving the referral must ensure that the patient is informed of the type of license held by the physician and the type of license held by any other practitioner who will be providing services to the patient.

When scheduling the initial examination or consultation following such referral, the patient should be allowed to decide to see the physician or any other licensed practitioner supervised by the physician and, before the initial examination or consultation, should sign a form indicating the patient's choice of practitioner.

The supervising physician must review the medical record of the initial examination or consultation and ensure that a written report of the initial examination or consultation is furnished to the referring practitioner within ten (10) business days following the completion of the initial examination or consultation.

F.S.A. § 458.348

6. What is the law in regard to supervisory relationships in medical office settings?

A physician who supervises a physician assistant at a medical office other than the physician's primary practice location, where the advanced registered nurse practitioner or physician assistant is not under the onsite supervision of a supervising physician, must comply with the following:

A. A physician who is engaged in providing primary health care services may not supervise more than four offices in addition to the physician's primary practice location. For the purpose of this subsection, "primary health care" means health care services that are commonly provided to patients without referral from another practitioner, including obstetrical and gynecological services, and excludes practices providing primarily dermatologic and skin care services, which include aesthetic skin care services.

B. A physician who is engaged in providing specialty health care services may not supervise more than two offices in addition to the physician's primary practice location. For the purpose of this subsection B, "specialty health care" means health care services that are commonly provided to patients with a referral from another practitioner and excludes practices providing primarily dermatologic and skin care services, which include aesthetic skin care services. The physician must be board certified or board eligible in dermatology or plastic surgery as recognized by the Board.

C. Physician must submit to the Board the addresses of all offices where he or she is supervising a physician's assistant which are not the physician's primary practice location.

D. All such offices that are not the physician's primary place of practice must be within 25 miles of the physician's primary place of practice or in a county that is contiguous to the county of the physician's primary place of practice. However, the distance between any of the offices may not exceed 75 miles.

E. The physician may supervise only one office other than the physician's primary place of practice except that until July 1, 2011 the physician may supervise up to two medical offices other than the physician's primary place of practice if the addresses of the offices are submitted to the Board before July 1, 2006. Effective July 1, 2011, the physician may supervise only one office other than the physician's primary place of practice, regardless of when the addresses of the offices were submitted to the Board.

F. A physician who supervises an office in addition to the physician's primary practice location must conspicuously post in each of the physician's offices a current schedule of the regular hours when the physician is present in that office and the hours when the office is open while the physician is not present.

F.S.A. § 458.348

7. What are the requirements for issuing prescriptions and orders; dispensing medications?

A supervisory physician may delegate to a fully licensed physician assistant the authority to prescribe any medication used in the supervisory physician's practice unless such medication is listed on the formulary created by the Board's Council for Physicians Assistants (see Section 8).

A fully licensed physician assistant may only prescribe such medication under the following circumstances:

A. A physician assistant must clearly identify to the patient that he or she is a physician assistant. Furthermore, the physician assistant must inform the patient that the patient has the right to see the physician prior to any prescription being prescribed by the physician assistant.

B. The supervisory physician must notify the department of his or her intent to delegate, on a department-approved form, before delegating such authority and notify the department of any change in prescriptive privileges of the physician assistant.

C. The physician assistant must file with the department, before commencing to prescribe, evidence that he or she has completed a continuing medical education course of at least 3 classroom hours in prescriptive practice, conducted by an accredited program approved by the boards, which course covers the limitations, responsibilities, and privileges involved in prescribing medicinal drugs, or evidence that he or she has received education comparable to the continuing education course as part of an accredited physician assistant training program.

D. The physician assistant must file with the department, before commencing to prescribe, evidence that the physician assistant has a minimum of 3 months of clinical experience in the specialty area of the supervising physician.

E. The physician assistant must file with the department a signed affidavit that he or she has completed a minimum of 10 continuing medical education hours in the specialty practice in which the physician assistant has prescriptive privileges with each licensure renewal application.

F. The physician assistant must acquire a a license and a prescriber number for the prescribing of medicinal drugs authorized within this paragraph upon completion of the foregoing requirements.

G. The prescription must be written in a form that complies with chapter 499 and must contain, in addition to the supervisory physician's name, address, and telephone number, the physician assistant's prescriber number. Unless it is a drug sample dispensed by the physician assistant, the prescription must be filled in a pharmacy permitted under chapter 465 and must be dispensed in that pharmacy by a pharmacist licensed under chapter 465. The appearance of the prescriber number creates a presumption that the physician assistant is authorized to prescribe the medicinal drug and the prescription is valid.

H. The physician assistant must note the prescription in the appropriate medical record, and the supervisory physician must review and sign each notation. For dispensing purposes only, the failure of the supervisory physician to comply with these requirements does not affect the validity of the prescription.

8. Are there any limitations on what a physician's assistant may prescribe?

Physician Assistants are not authorized to prescribe the following medicinal drugs, in pure form or combination:

A. Controlled substances, as defined in Chapter 893, F.S.;

B. Antipsychotics;

C. General, spinal or epidural anesthetics;

D. Radiographic contrast materials;

E. Any parenteral preparation except insulin and epinephrine. Parenteral includes: intravenous, subcutaneous, intramuscular, and any route other than the alimentary canal; however, it does not include topical or mucosal application. Nothing in this formulary prohibits a physician assistant from administering a parenteral drug under the direction or supervision of the supervising physician.

Nothing prohibits a supervising physician from delegating to a physician assistant the authority to order medicinal drugs for a hospitalized patient of the supervising physician, nor does anything herein prohibit a supervising physician from delegating to a physician assistant the administration of a medicinal drug under the direction and supervision of the physician.

F.S.A. § 458.347

III. NURSE PRACTITIONER

1. What qualifications must an individual have to be a nurse practitioner?

The Florida State Board of Nursing (SBN) will issue a nurse practitioner (NP) license to an applicant if he or she:

A. Is at least 18 years of age;

B. Is a registered professional nurse;

In order to acquire a license as a professional nurse, the SBN requires applicants to meet A and B above and have:

1. Satisfactory completion of a formal postbasic educational program of at least one academic year, the primary purpose of which is to prepare nurses for advanced or specialized practice.

2. Certification by an appropriate specialty board. Such certification shall be required for initial state certification and any recertification as a registered nurse anesthetist or nurse midwife. The board may by rule provide for provisional state certification of graduate nurse anesthetists and nurse midwives for a period of time determined to be appropriate for preparing for and passing the national certification examination.

3. Graduation from a program leading to a master's degree in a nursing clinical specialty area with preparation in specialized practitioner skills.

F.S.A. § 464.012

2. What duties may be performed by an ARNP?

A. An advanced registered nurse practitioner (ARNP) may perform those functions within the framework of an established protocol with a supervisory physician which may include:

1. Monitor and alter drug therapies.

2. Initiate appropriate therapies for certain conditions.

3. Order diagnostic tests and physical and occupational therapy.

B. In addition to the general functions specified in subsection 2A, an advanced registered nurse practitioner may perform the following acts within his or her specialty:

1. A certified registered nurse anesthetist may, to the extent authorized by established protocol approved by the medical staff of the facility in which the anesthetic service is performed, perform any or all of the following:

(i) Determine the health status of the patient as it relates to the risk factors and to the anesthetic management of the patient through the performance of the general functions.

(ii) Based on history, physical assessment, and supplemental laboratory results, determine, with the consent of the responsible physician, the appropriate type of anesthesia within the framework of the protocol.

(iii) Order, under the protocol, preanesthetic medication.

(iv) Perform under the protocol procedures commonly used to render the patient insensible to pain during the performance of surgical, obstetrical, therapeutic, or diagnostic clinical procedures. These procedures include ordering and administering regional, spinal, and general anesthesia; inhalation agents and techniques; intravenous agents and techniques; and techniques of hypnosis.

(v) Order or perform monitoring procedures indicated as pertinent to the anesthetic health care management of the patient.

(vi) Support life functions during anesthesia health care, including induction and intubation procedures, the use of appropriate mechanical supportive devices, and the management of fluid, electrolyte, and blood component balances.

(vii) Recognize and take appropriate corrective action for abnormal patient responses to anesthesia, adjunctive medication, or other forms of therapy.

(viii) Recognize and treat a cardiac arrhythmia while the patient is under anesthetic care

(ix) Participate in management of the patient while in the postanesthesia recovery area, including ordering the administration of fluids and drugs.

(x) Place special peripheral and central venous and arterial lines for blood sampling and monitoring as appropriate.

2. A certified nurse midwife may, to the extent authorized by an established protocol which has been approved by the medical staff of the health care facility in which the midwifery services are performed, or approved by the nurse midwife's physician backup when the delivery is performed in a patient's home, perform any or all of the following:

(i) Perform superficial minor surgical procedures.

(ii) Manage the patient during labor and delivery to include amniotomy, episiotomy, and repair.

(iii) Order, initiate, and perform appropriate anesthetic procedures.

(iv) Perform postpartum examination.

(v) Order appropriate medications.

(vi) Provide family-planning services and well-woman care.

(vii) Manage the medical care of the normal obstetrical patient and the initial care of a newborn patient.

3. The nurse practitioner may perform any or all of the following acts within the framework of established protocol:

(i) Manage selected medical problems.

(ii) Order physical and occupational therapy.

(iii) Initiate, monitor, or alter therapies for certain uncomplicated acute illnesses.

(iv) Monitor and manage patients with stable chronic diseases.

(v) Establish behavioral problems and diagnosis and make treatment recommendations.

F.S.A. § 464.012

3. What are the requirements for issuing prescriptions and orders or dispensing medications?

An ARNP may only prescribe medications in collaboration with a supervising physician.

Florida does not allow ARNPs to prescribe controlled substances.

4. What are the requirements for Employers of Advanced Registered Nurse Practitioners?

An Advanced Registered Nurse Practitioner shall only perform medical acts of diagnosis, treatment, and operation pursuant to a protocol between the ARNP and a Florida-licensed physician or dentist. The degree and method of supervision, determined by the ARNP and the physician or dentist, must be specifically identified in the written protocol and must be appropriate for prudent health care providers under similar circumstances. General supervision by the physician or dentist is required unless otherwise required. Physicians must determine the number of ARNP's by considering the following factors:

A. risk to patient;.

B. educational preparation, specialty, and experience of the parties to the protocol;

C. complexity and risk of the procedures;

D. practice setting, and

E. availability of the physician or dentist.

64 FL ADC 64B9-4.010

5. What are the Standards for joint protocols between NP and collaborating physicians?

The protocol must be:

A. in writing, signed by all parties;

B. include the ARNP's name, address, and certificate number;

C. include the name, address, license number, and DEA number of the supervising physician;

D. describe the nature of practice, practice location, including primary and satellite sites;

E. state the date the protocol was developed and dates amended with signatures of all parties;

F. include a description of the duties of the ARNP;

G. include a description of the duties of the physician (which shall include consultant and supervisory arrangements in case the physician is unavailable);

H. describe the management areas for which the ARNP is responsible, including

1. the conditions for which therapies may be initiated;

2. the treatments that may be initiated by the ARNP, depending on patient condition and judgment of the ARNP; and

3. the drug therapies that the ARNP may prescribe, initiate, monitor, alter, or order;

I. include a provision for annual review by the parties; and

J. include specific conditions and a procedure for identifying conditions that require direct evaluation or specific consultation by the physician.

Any alterations to the protocol or amendments should be signed by the ARNP and a Florida-licensed medical doctor, osteopathic physician and filed with the Florida Department of Health within 30 days of the alteration to be kept in the Florida Department of Health for filing purposes only. After the termination of the relationship between the ARNP and the supervising professional, each party is responsible for insuring that a copy of the protocol is maintained for future reference for a period of four (4) years.

64 FL ADC 64B9-4.010

5. What is the penalty for failure to establish and implement joint protocols consistent with the standards set forth by the SBN?

Any violation of the joint protocol by an advanced practice nurse or physician may be deemed professional misconduct or other grounds for disciplinary sanction by his or her respective licensing board.

Copyright Kern Augustine Conroy and Schoppmann, P.C. Used with permission.