Frequently Asked Questions - Advanced Practice Registered Nurse

APRN Application

What is the first step to obtaining an advanced practice registered nurse (APRN) license in Texas?

A nurse who wishes to be licensed to practice as an APRN in the state of Texas must be licensed as a Registered Nurse in Texas or have a current, valid RN license with multistate privilege...

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Can I send my RN endorsement application and my APRN application in together?

Yes, however we will not grant any level of approval until you hold a current, valid RN license (temporary or full) or privilege to practice in the state of Texas.

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How can I obtain the APRN application?

If you wish to submit your application online, please click here.

read the application instructions and Rule 221 (and 222 if you are applying for prescriptive authority) carefully to be certain you meet the requirements outlined in Board rules. If you submit your application online, please be certain to provide us with the supporting documentation as indicated in the completion packet that is part of the online application.

may grant interim approval when it appears that the applicant will meet the requirements for full licensure as an APRN in Texas but additional information is needed. This type of approval is granted for a period not to exceed 120 days. Per Rule 221.6 (b)(3), extensions of the interim approval period may not be granted.

license from the Texas Board of Nursing before you may claim to be an advanced practice registered nurse or hold yourself out as an advanced practice registered nurse in this state. You may not use a title or any other designation tending to imply that you are licensed as an advanced practice registered nurse without current licensure from the Texas Board of Nursing.

The Compact status is only extended to those nurses who meet requirements for licensure in their home state that is a member of the Nurse Licensure Compact. Proof of a nurses's primary state of residence may be required. Documentation to verify this information may include, but is not limited to, a driver's license with a home address, voter registration card displaying a home address, and/or federal income tax return declaring the primary state of residence. A nurse who permanently moves from one Compact state to another must obtain an RN license in the new home state. For more information on the Nursing Licensure Compact, click here: https://www.ncsbn.org/nlc.htm. For a list of current Compact states, please click here: https://www.ncsbn.org/Implementation_dates_list.pdf.

Please note that at this time, Texas has not implemented the APRN compact. Therefore, in order to practice in Texas, you must have a privilege to practice on your RN license from your home state that is party to the Nurse Licensure Compact. If your primary state of residence is not party to the Nurse Licensure Compact, you must obtain a Texas RN license.

This may take up to three months to complete if an eligibility determination is required. Additional fees may also be required. If additional fees are needed, you will be notified in writing. No approvals will be granted until clearance is received from the enforcement department.

Please note: Providing false information on your application is a violation of board rule and the Texas Penal Code. Additional information is available in the board's disciplinary sanction policy on lying and falsification.

role and population focus area. You cannot legally expand your scope of practice from one area of licensure to another without meeting the educational and licensure requirements set by the board (see above). This means you must submit a separate application and fee for each APRN role and population focus area in which you are seeking licensure.

This is also the case for prescriptive authority. Although you have prescriptive authority in one role and population focus area, you must apply for and meet the requirements for prescriptive authority in each APRN category in which you wish to be licensed to practice.

The Texas Board of Nursing (Board) recognizes specific certification examinations for specific roles and population focus areas. The Board has an obligation to the public it serves and to its licensees to verify that each certification examination tests for entry level competence in the particular advanced practice role and population focus area. Therefore, the Board must have a process in place whereby each examination is reviewed for initial recognition and on a recurring basis in order to be certain the certification process continues to meet the criteria set forth by the Board in the “Criteria for Evaluation of National Certification Examinations for Recognition from the Texas Board of Nursing,” adopted in October 2003.
The National Council of State Boards of Nursing (NCSBN) also has a review process in place for advanced practice certification examinations. The NCSBN’s examination review criteria have been reviewed and determined to be substantially equivalent to the evaluation criteria adopted by the Board. Therefore, it shall be the policy of the Board to recognize certification examinations that have previously been reviewed and approved by the NCSBN in lieu of completing a separate evaluation. This shall include both review of new examinations as well as recurrent reviews of existing examinations.
The Board reserves the right to complete its own review of any certification examination at any time. Factors that may trigger a review include but are not limited to the following:

• Unusually high or low pass rate
• New examinations that have not yet and/or will not be reviewed by NCSBN
• Substantive concern from the community of interest related to the quality of the examination content or the certification process

Should the NCSBN review an examination as a result of any of the aforementioned factors, the Board may elect to accept the NCSBN’s review in lieu of completing its own evaluation.

Adopted July 21, 2005

Why are APRNs required to be nationally certified?

There is no licensure examination for APRNs. Therefore, national certification examinations serve to assess the nurse’s knowledge of the APRN core and role competencies across the population focus area for which the nurse was educated and is seeking licensure (Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education, 2008). This is one mechanism by which boards of nursing can provide assurance to the public that the APRN demonstrated the minimum level of competency for entry into practice in the APRN role and population focus area prior to issuing an APRN license.

I completed my APRN education prior to January 1, 1996. Do I have to be nationally certified?

The answer to your question depends on whether the program you completed was accredited by a national nursing education accreditation organization recognized by the Texas Board of Nursing (Board) at the time you completed the APRN program. Please note that the accreditation must have covered the specific APRN program or track you completed. Also, please be aware that the entity that accredits the program now may not have accredited the program at the time you completed it.  If your program met this accreditation requirement, you are not required to maintain national certification as a requirement to maintain APRN licensure in Texas. However, if your program was not accredited by a national nursing education accreditation organization recognized by the Board at the time you completed it, you must maintain your national certification in order to maintain APRN licensure in Texas.

I was licensed as an APRN in another state where national certification was not required. Do I need to get certified to endorse my APRN license to Texas?

Yes. Texas bases all APRN licensure decisions on whether the education and certification requirements as specified in Board Rule have been met. It is not possible for staff to grant an exemption to the national certification requirement, and the Board has never granted such an exemption. National standards for APRN licensure require licensure decisions that are based on formal education and national certification in the APRN role and population focus area, and the Board’s rules are consistent with this standard. Board staff consider all applications for licensure based on the standards contained in Board Rule.

Does my national certification allow me to practice before I get my Texas APRN license since it is a national document?

No. National certification organizations do not grant authority to practice in any jurisdiction, including Texas. You must have a Texas APRN license in order to practice as an APRN in Texas.

The national certifying organization says I can use my APRN certification credential now that I have passed my test. Is this correct?

APRN titles are protected titles in the state of Texas. Board Rule 221.2(c)(2) prohibits the use of any titles that imply the bearer is an APRN if the individual is not licensed by the Board as an APRN in the state of Texas. Certification credentials for APRNs include the use of various APRN titles. It could be confusing to patients and to the public who may not readily understand the differences between APRN licensure and certification. You may use your national certification credential when you are licensed by the Texas Board of Nursing as an APRN if you choose to do so. Board Rule 221.11 requires only that you use your RN credential and the APRN licensure title that is specified on your APRN license (e.g., RN, FNP or RN, CNS-PMH). Use of certification credentials is optional.

If I am licensed in more than one APRN role and/or population focus area, do I have to be certified in each of the additional roles and/or population focus areas?

Yes. APRN licensure is specific to each role and population focus area. Therefore, in order to obtain or maintain licensure in each role and population focus, you must maintain national certification in each.

The Board recognizes more than one national certification examination for my APRN role and population focus area. Does the Board have a preference for which exam I should take?

No. The Board has never had a preference for one certification organization over another. All certification organizations that offer APRN exams required for licensure purposes are held to the same quality standard. Neither the Board nor its staff can advise you which exam you should take. We recommend that you review information regarding the certification process and determine which exam would be best for you. Questions regarding the process should be directed to the certifying organization. 

I have a question about the certification process or renewal of my certification. Can the Board help me with those questions?

No. Board staff cannot speak as experts on requirements that are not within the Board’s jurisdiction. Questions about certification requirements and certification renewal requirements must be directed to the appropriate certification organization. Certification requirements are not determined by the Board, and only the certification organization has the authority to advise on its requirements.

I was certified, but my certification accidentally lapsed. Can I still practice since my APRN license is current?

If your certification has lapsed, you are not eligible to practice as an APRN in Texas until your certification or recertification status is current (Rule 221.8). The Texas Board of Nursing is not notified by the certifying bodies when national certifications lapse or expire, so it is incumbent upon you as an APRN to recognize when your national certification has lapsed or expired and cease practice in the APRN role and population focus area. You may continue to practice as a registered nurse until your national certification or recertification has been returned to current status.

Is the Texas Board of Nursing automatically notified when I pass my certification examination or if my certification status changes?

Generally, the answer to this question is no. Some certifying organizations provide notice to boards of nursing when a certificate holder’s status changes; however, this is not the case for all certifying organizations. If your certification status changes for any reason, you should submit a copy of the status change document you received from the certification organization to the Texas Board of Nursing. You may submit a copy via email to [email protected], by fax to 512-305-8101—Attention: APRN Office, or by postal mail to Texas Board of Nursing, Attention APRN Office, 333 Guadalupe, Ste 3-460, Austin, TX, 78701.

The certification organization will not let me sit for the examination because they said I completed my program too long ago. Can the Board require them to let me sit for the certification examination?

No. The national certification organizations have authority to determine the requirements to sit for national certification. The Board has no authority to require these organizations to amend or waive their published eligibility requirements. You must comply with the certification requirements set by the organization.

If I am not eligible to obtain national certification, is there something I can do in lieu of the certification requirement so I can obtain my Texas APRN license?

No. Requiring national certification in the advanced practice role and population focus area is a national standard for APRN licensure. The Texas Board of Nursing has required national certification as a requirement for APRN licensure since January 1996.

I obtained a specialty certification related to the specialty area in which I currently practice. May I maintain the specialty certification in lieu of the certification in the role and population focus area since my practice is in the specialty area?

No. You must maintain your national certification in the advanced practice role and population focus area of licensure in order to maintain your Texas APRN license. Specialty certifications demonstrate expertise in a particular area of your practice and may be utilized for the purpose of demonstrating knowledge related to a specific health care need (e.g., oncology, orthopedics, or diabetes education). The national certification that you are required to obtain and maintain for APRN licensure purposes is based on your formal education in an APRN role and population focus area. Specialty certification does not demonstrate the breadth of your education and expertise in the full scope of your role and population focus area and is therefore not accepted for APRN licensure purposes.

If I attain national certification in an additional role and/or population focus area, will this allow me to automatically expand my scope of APRN practice since I already have an APRN license?

No. The Board does not issue a generic APRN license; rather, the APRN license is specific to an advanced practice role and population focus area. National certification in an additional role and/or population focus does not automatically expand your APRN scope of practice in Texas. To expand your scope to the additional role and/or population focus area, you must meet the educational and licensure requirements to do so and apply for expanded licensure through the Texas Board of Nursing.

I completed my APRN program in 1992 and am not required by the Texas Board of Nursing (Board) to maintain national certification to maintain my license. However, my employer says I have to be nationally certified. Can my employer require this if the Board does not?

Yes. The Board determines requirements for licensure only; the Board does not set requirements for employment settings. Employers may set requirements for employment that are more restrictive than those set by the Board for licensure purposes. Therefore, if your employer requires you to hold national certification to practice in that setting, you must meet this requirement as a condition of your employment.

I am trying to get credentialed as a Medicare provider. They refuse to credential me because I am not nationally certified.  Can the Board help me?

When it comes to credentialing as a Medicare provider, federal law determines the requirements for credentialing. If federal law requires national certification as a requirement for credentialing, then you must be nationally certified to be credentialed. Although you may be licensed, third party entities, including the Center for Medicare and Medicaid Services may set their own requirements for providers who wish to be credentialed for reimbursement. The Texas Board of Nursing has no jurisdiction over these requirements nor can it require any other entity to credential you.

Will my national certification meet the requirements for continuing education?

Attaining, maintaining or renewing national certification will meet the requirement for 20 contact hours of continuing education for APRNs in accordance with Rule 216.3(c). National certification cannot be used to meet the continuing education requirements for prescriptive authority nor can it serve to meet certain specific continuing education requirements such as the requirement for two contact hours of continuing education targeted for nursing jurisprudence and nursing ethics.

I am a family nurse practitioner who obtained national certification as an emergency nurse practitioner. How can I add this to my license?

Known as the Healing Art Identification Act, Texas Occupations Code, Chapter 104 addresses the use of the term doctor.   All nurses must know and comply with the Nursing Practice Act and Board’s Rules as well as all federal, state, and local laws [Board Rule §217.11(1)(A)].  To comply with this law, a nurse is required to include the degree that allows him/her to use the title Dr. ___ as a credential and indicate the profession being practiced.  The Advanced Practice Registered Nurse (APRN) must be identified both as an RN as well as use the appropriate advanced practice title that has been authorized by the Board of Nursing.

The Nursing Practice Act and Board’s Rules do not prohibit the use of ‘Dr. ____’; however, based on requirements in the Texas laws, doctorally prepared nurses cannot simply identify themselves as Dr. _____.  The nurse must include the academic credentials and licensure level with appropriate APRN title.   Board staff recommends review of “When the Profession is Nursing and the Title is Doctor….” available in the July, 2011 BON Quarterly Newsletter, page 4.

However, all nurses frequently find themselves in the position of needing to learn new procedures. Nurses at all levels of licensure are obligated to make a reasonable effort to obtain orientation/training for competency when encountering new equipment, technology, or unfamiliar patient care situations [Rule 217.11(1)(H)]. The BON also holds all nurses, including advanced practice registered nurses, accountable for their own continuing competence in nursing practice and individual professional growth [Rule 217.11(1)(R)]. The most appropriate mechanism for learning the new procedure and documenting competence will depend on the nature of the procedure. It is imperative that you and the physician work together to find an existing educational activity or develop a program that will prepare you appropriately to perform the procedure and provide the concomitant advanced practice nursing care to the patient.

It is important to remember that there is more to this issue than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology (depending on the nature of the procedure) as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided. As an advanced practice registered nurse, you retain professional accountability for any advanced practice registered nursing services you provide [Rule 221.13(e)].

population focus from the BON. When incorporating a new patient care activity or procedure into one's individual scope of practice, the board expects the advanced practice registered nurse to verify that the activity or procedure is consistent with the professional scope of practice for the licensed role and population focus and permitted by laws and regulations in effect at the time. For example, a women's health nurse practitioner or nurse-midwife who wishes to incorporate performance of colposcopies in his/her practice may do so without obtaining an additional licensure to practice from the BON because this activity is consistent with the professional scope of practice for those roles.

If the activity is not consistent with the professional scope of practice for the licensed role and population focus, additional formal education and authorization from the BON in the second role and/or population focus is required. For example, an advanced practice registered nurse who is licensed to practice in gerontological nursing wishes to provide advanced practice nursing care to all adult patients. In order to do so, he/she must complete education that will prepare him/her in an advanced practice role and population focus that encompasses advanced practice registered nursing care of adults of all ages. Rule 221.4(c) requires that this additional education meet the curricular requirements outlined in Rule 221.3, relating to advanced practice registered nursing education. After completing the additional formal education, you must obtain national certification in the additional role and population focus as well as licensure to practice in the particular role and population focus from the BON before you begin practicing in the additional population focus or role.

experiences that provided him/her with the knowledge, skills, and competence to provide nursing care to patients regardless of age, diagnosis or practice setting. Therefore, RN licensure is not limited based on practice setting or specific patient population.

Similarly, physicians complete broad education that encompasses the provision of medical care to patients across the lifespan, regardless of diagnosis or practice setting. Physicians do not specialize or sub-specialize in medical school; rather, they do so after completing their initial medical education.

In order to be licensed as an advanced practice registered nurse, this individual completed additional educational preparation to expand his/her scope of practice beyond that of the RN. His/Her advanced practice registered nursing education, however, focused on expanding his/her nursing scope of practice in a particular advanced practice role and population focus (e.g. anesthesia, women's health, gerontology). Although he/she may have gained experience in a particular area in the RN role, experiences gained as an RN are not equivalent to and cannot replace formal education in the particular advanced practice role and population focus.

• Is licensed to practice as an RN,
• Has completed a nurse first assistant educational program approved or recognized by an organization recognized by the board, and
• Is either (1) certified in perioperative nursing (CNOR) OR (2) recognized by the board as an advanced practice registered nurse and qualified by education, training or experience to perform the tasks involved in perioperative nursing.

Therefore, if you are recognized by the board as an advanced practice registered nurse and qualified by education, training or experience to perform the tasks involved in perioperative nursing, you will only need to complete a nurse first assistant educational program. The nurse first assistant educational programs recognized by the Texas Board of Nursing are the nurse first assistant educational programs that are included on the Competency and Credentialing Institute's (CCI's) list of acceptable RNFA programs. You may access that list of programs on-line at the following URL: CCI Competency & Credentialing Institute, Steps to Become a CRNFA, http://cc-institute.org/crnfa/certification/steps/programs.aspx.

Please note: Advanced practice registered nurses who are recognized by the BON as nursemidwives may complete the American College of Nurse-Midwives' (ACNM's) process for incorporating first assistant responsibilities for obstetrical and/or gynecological procedures into their scopes of practice in lieu of a course accepted by CCI.

federal laws, other state laws (e.g., Texas Health and Safety Code), or JCAHO requirements] significantly impact an advanced practice registered nurse's ability to provide a specific service. Although the BON may state that the performance of a particular procedure or provision of a specific patient care activity is within an advanced practice registered nurse's professional scope of practice, the advanced practice registered nurse may not perform the procedure or provide the particular service if other laws and regulations prohibit this.

The Standards of Nursing Practice in Rule 217.11 remind nurses at all levels of licensure that they are obligated to know and conform to the Nursing Practice Act and BON rules in addition to all federal, state and local laws, rules or regulations affecting their current area of nursing practice [(1)(A)]. BON staff cannot speak as experts on other agencies' laws and regulations. Therefore, it is important for advanced practice registered nurses to investigate whether other laws or regulations prohibit the performance of a procedure or patient care activity before they perform it.

The patient population, individual advanced educational program content and competencies attained in the advanced practice registered nursing educational program always serve as the foundation for advanced practice registered nursing practice. Rule 221.13(b), relating to the core standards for advanced practice, further states that advanced practice registered nurses must practice within the role and population focus appropriate to their educational preparation.

Although both programs included content related to a particular specialty or sub-specialty, the depth of the content included in each program varies significantly. As in the example of OB/GYN specialty content for the FNP and WHNP, the FNP educational program provided some content related to OB/GYN. It did not, however, include OB/GYN specialty content to the same depth that the WHNP's program did. Therefore, although there will be overlap in the scope of the services each advanced practice registered nurse provides in this setting, there may be procedures or patient care activities that are within the WHNP's scope of practice that are not within the FNP's scope of practice in this particular setting. Each advanced practice registered nurse is responsible for practicing within the role and population focus licensed by the board and appropriate to his/her educational preparation. Additionally, each advanced practice registered nurse is responsible for recognizing when he/she is in danger of exceeding his/her personal and professional scope of practice.

assistive personnel utilizing the applicable RN Delegation Rules 224 or 225 as appropriate and in compliance with Rule 217.11(3)(B). Advanced practice registered nurses are not authorized to exceed the delegation criteria in Rules 224 and 225.

With regard to other nurses, it is important to note that an advanced practice registered nurse may make an assignment to another nurse that takes into account his/her scope of practice and level of licensure [Rule 217.11(1)(S)]. An advanced practice registered nurse may not assign tasks to RNs or LVNs that exceed the RN or LVN scope of practice, even if the advanced practice registered nurse agrees to co-sign the RN's or LVN's documentation. An advanced practice registered nurse's co-signature for something that is beyond the RN's or LVN's scope of practice does not legitimize the RN's or LVN's actions. A nurse never functions "under the license" of another nurse nor does a nurse "delegate" to another licensed nurse. For more information see Texas Board of Nursing Laws & Rules

Nurses should use their professional judgment when deciding to maintain current CPR certification, taking into consideration whether they are employed in patient care settings in which CPR may be necessary to resuscitate and stabilize a client condition [(217.11(1)(M)]. Nurses have a responsibility to maintain continuing competence in nursing practice through educational opportunities that promote individual professional growth (Board Rule 217.11(1)(G)(H)(R). 

A do-not-resuscitate/out of hospital do-not-resuscitate order is a medical order that must be given by a physician and in the absence thereof; it is generally outside the standard of nursing practice to determine that CPR will not be initiated. The initiation of CPR does not require a physician’s order in the absence of do-not-resuscitate/out of hospital do-not-resuscitate order.

In general, the Texas Nursing Practice Act and Board Rules and Regulations establish a nurse’s duty to initiate CPR and require every nurse, regardless of expertise, specialty, or practice setting to provide safe and effective care for clients [Board Rule 217.11(1)(B)].  Licensure laws and rules do not specifically require a nurse to have a current CPR card in order to perform CPR or utilize other life-saving interventions for a client. Instead, the minimum standards of nursing practice addressed in Board Rule 217.11 require a nurse to “implement measures to promote a safe environment for clients and others” as well as “institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications.”

This position statement is specific to long-term care facilities and is not to be construed as applicable to other healthcare settings in which nurses are employed.

After assessment of the resident is completed and appropriate interventions are implemented, documentation of the circumstances and the assessment of the resident in the medical record are required. 

CPR should not be delayed to review the client’s medical record or chart to determine the client’s wishes or search physician orders for do-not-resuscitate/out of hospital do-not-resuscitate documentation. Employers and nurses should take a proactive approach to ensure that healthcare setting policies are in place to ascertain a physician’s order for resuscitative status upon admission and to update the plan of care to anticipate the immediate need to access a client’s current resuscitation status physician’s order so that CPR is initiated appropriately and without delay.

Can an RN or an APRN pronounce death?

Texas Statutes and Rules and Regulations outside of the nursing licensure laws and rules govern who can pronounce death, and only those legally authorized to pronounce death may do so (i.e., physician, justice of the peace). Texas regulations regarding pronouncement of death may be found in Texas Health and Safety Code Chapter 671 and Texas Administrative Code Chapter 193 (Texas Administrative Code, Title 22, Part 9, Chapter 193.18) 

The Texas Health and Safety Code chapter 671 requires that in order for an RN to pronounce death, the facility, institution, or entity must have a written policy which is jointly developed and approved by the medical staff or medical consultant and the nursing staff, specifying under what circumstances an RN can make a pronouncement of death. 
An RN and/or an APRN can pronounce death when a client has executed a properly documented do-not-resuscitate/out of hospital do-not-resuscitate physician orders and when the employer has policies and procedures in place to acknowledge that the RN and/or APRN may pronounce death.  An RN may not sign a death certificate under any circumstances. However, an APRN may sign a death certificate under the following circumstances:

• The patient has executed a written certification of terminal illness, has elected to receive hospice care, and is receiving hospice services from a qualified hospice provider; or
• The patient is receiving palliative care.

LVNs conduct focused assessments that include making nursing observations and recognizing significant changes in a client’s condition. These observations and changes in condition are reported to the physician. LVNs may not accept an order to pronounce death; however, after LVNs communicate their findings which include presumptive and/or obvious clinical signs of irreversible death to the physician and in accordance with facility policy, the LVN may accept a reasonable physician’s order regarding the care of the client (i.e., notification of family and funeral home and postmortem care).  TMB Rule 193.18 requires LVNs to inform physicians of the following minimum findings:

• Absence of palpable pulse for a minimum of 60 seconds;
• Absence of discernible blood pressure for a minimum of 60 seconds;
• Absence of evidence of respiration for a minimum of 60 seconds;
• Absence of evidence of heartbeat for a minimum of 60 seconds; and
• Other information as the physician may require.

It is imperative that LVNs document their focused assessment findings, nursing interventions, and communication with physician and physician’s orders.

The Board recommends employers consider the following references when establishing policies and procedures in the healthcare setting

• Board Rule 217.11, Standards of Nursing Practice
• Position Statement 15.27, LVN Scope of Practice
• Position Statement 15.28, RN Scope of Practice
• Position Statement 15.14, Duty of a Nurse in Any Practice Setting
• Position Statement 15.2, The Role of the Licensed Vocational Nurse in the Pronouncement of Death
• Position Statement 15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility
• Frequently Asked Question, RN Pronouncement of Death
• Texas Administrative Code Chapter 193 (22 TAC, §193.18
• Texas Health and Safety Code Chapter 671

Revised 2018

Nurses have a duty to report patient information, including mental health information, to members of law enforcement, a patient's family and others when a patient is a serious danger to himself or others. The confidentiality rule also known as the Health Insurance Portability and Accountability Act (HIPAA) does not prevent nurses, when acting in "good faith", from reporting necessary information about a patient to those who may be able to prevent or lessen a danger to a patient or the public. The confidentiality rule is balanced to protect a patient's health information while allowing information to be disclosed that could protect both the public and a patient from harm.

The Texas Board of Nursing has developed standards of nursing practice that apply to nurses' duty to report confidential health information and require licensed vocational nurses, registered nurses, and advanced practice registered nurses to: understand and follow the laws applicable to their area of practice; provide a safe environment for a patient and others; and respect a patient's right to confidentiality and disclose information to the proper authorities when necessary to protect a patient and the public from harm. To learn more about the standards of nursing practice, see Rule 217.11, Standards of Nursing Practice.

facility-based protocols must also be submitted within this time frame, each licensing board has the authority to request this information. Failure to provide the requested information could result in disciplinary action against the professional license.

register the delegation with the Texas Medical Board. There is a portion of the registration that you must complete and then the physician must go in and complete his/her portion of the registration and certify the delegation. Please note that Texas Board of Nursing staff does not have access to this system and cannot assist you with this process.

patient’s release from the hospital, as defined by §551.003, Occupations Code and §481.002, Health and Safety Code. A prescription is an order to dispense a drug or device to a patient for self-administration as defined by §551.003, Occupations Code.

it is important to consider that the physician must be able to complete chart reviews and the APRN and physician must conduct monthly meetings as required by Texas law. The physician should also be accessible to the APRN to provide required delegation and consultation as necessary. If the physician is not accessible for a period of time, an alternate physician should be designated.

meet more frequently than required by law. You may not meet less frequently than what is required by law. An APRN should meet the requirements of the prescriptive authority agreement which may have more frequent meetings required.

your delegating physician via internet technology, teleconference or via other mechanisms that permit you and the delegating physician to have a meaningful dialogue on the required elements of the monthly meeting. Monthly meetings must be documented and include: the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and discussion of patient care improvement. It is important to remember that meetings conducted via technology must take into consideration the need to keep protected health information confidential.

disciplinary order that specifically prohibits entering into a prescriptive authority agreement. If the Texas Board of Nursing limits an APRN’s authority to order or prescribe drugs or devices, the licensee may enter into a prescriptive authority agreement and order or prescribe drugs and devices only to the extent permitted by the board order.

includes disciplinary action taken by licensing boards in other states. Once you are a party to a prescriptive authority agreement, you are required to immediately notify the other party/parties to the agreement if you receive notice that you are the subject of an investigation.

• Name, address, and all professional license numbers of all parties to the agreement;
• State the nature of the practice, practice location or practice settings;
• Identify the types of categories or 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 consultations and referrals;
• Provide a plan for addressing patient emergencies;
• State the general process for communication and sharing information related to the care and treatment of patients; and
• Describe a quality assurance and improvement plan and how it will be implemented. The plan must include plans for chart reviews and monthly meetings.
• If alternate physician supervision is to be utilized the prescriptive authority agreement must include the information outlined in Board Rule 222.5(8).
• Must be dated and signed by the parties to the agreement.

to the prescriptive authority agreement. The number may vary from one practice setting to another. Factors such as the length of time the APRN has been in practice, the length of time the physician and APRN have practiced together, whether the parties to the prescriptive authority agreement practice together in the same practice setting, and the complexity of patient care needs should be given consideration when making this determination. That said, there has been no change in the law that requires that a physician must provide adequate supervision of delegates.

The meetings must occur at least monthly.

No. You must have monthly meetings as part of your quality assurance and improvement plan.

The prescriptive authority agreement designates who may serve as an alternate physician if alternate physician supervision will be utilized. If an alternate physician(s) will participate in the quality assurance and improvement meetings with the APRN, this information must be included in the prescriptive authority agreement.

No. Free standing clinics, centers or other medical practices that are owned or operated by or associated with a hospital or long term care facility that are not considered facility based practices. Prescriptive authority agreements are required in these settings.

Although it is possible to use a prescriptive authority agreement in a hospital or long term care facility-based practice, it is not required. You may practice under facility-based protocols in these settings. APRNs must exercise prescriptive authority under one of these delegation mechanisms.

A physician may delegate prescriptive authority via facility-based protocol at no more than one licensed hospital or no more than two long term care facilities.

In a hospital facility-based practice, the delegating physician may be the medical director, the chief of medical staff, the chair of the credentialing committee, a department chair, or a physician who consents to the request of the medical director or chief of the medical staff to delegate.

In a long term care facility based practice, delegation is by the medical director.

providing anesthesia or anesthesia-related services, The CRNA may provide these services in accordance with facility policy or medical staff bylaws pursuant to a physician’s order for anesthesia or anesthesia-related services. CRNAs are not required to have prescriptive authority from the Texas Board of Nursing nor are they required to be registered with the Texas Medical Board. The delegation is limited to the hospital or ambulatory surgery center in which the CRNA is credentialed to practice.

In outpatient anesthesia settings, the drugs administered and devices applied by a CRNA who provides anesthesia or anesthesia-related services are supplied by the practice setting. Therefore, they are ordered for use in that setting by the surgeon. Just as in the hospital or ambulatory surgery center, the CRNA selects and administers drugs and applies devices pursuant to an order to administer anesthesia or an anesthesia-related service in this setting. Because the surgeon has supplied the drugs and devices for the purpose of providing anesthesia or anesthesia-related services, the CRNA is not required to have prescriptive authority for this purpose. All parties are required to follow the laws and regulations for ordering, storing, wasting and tracking the use of medications and devices in these settings.

If CRNAs are practicing in settings in which they are writing prescriptions, such as a CRNA who may be working with a pain management specialist, the CRNA must have prescriptive authority and all requirements for delegation of prescriptive authority must be met. This includes requirements for a prescriptive authority agreement or facility-based protocol as appropriate and registration of physician delegation on the Texas Medical Board’s website. If controlled substances will be prescribed, the CRNA must also have the required controlled substance registrations (DEA and DPS). CRNAs with prescriptive authority may only order or prescribe drugs and devices for the purpose of provision of anesthesia or an anesthesia-related service.

Links to Outpatient Anesthesia Rules:

• Texas Medical Board Rule 192.2:
  http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=192&rl=2
• Texas Board of Nursing Rule 221.16:
  http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=11&ch=221&rl=16]\

1. in a hospital facility-based practice, in accordance with policies approved by the hospital's medical staff or a committee of the hospital's medical staff as provided by the hospital's bylaws to ensure patient safety and as part of care provided to a patient who:
   1. has been admitted to the hospital for an intended length of stay of 24 hours or greater; or
   2. is receiving services in the emergency department of the hospital; or
2. as part of the plan of care for the treatment of a person who has executed a written certification of a terminal illness, has elected to receive hospice care, and is receiving hospice treatment from a qualified hospice provider.

No. A free standing emergency department is not located within the hospital anddoes not qualify as an eligible site for delegation of schedule II authority. The physician may only delegate authority to prescribe controlled substances in schedules III through V in this setting. Authority to prescribe dangerous drugs, nonprescription drugs and devices may be delegated in any setting.

APRNs must consult with the delegating physician for refills of a prescription for controlled substances after the initial 90-day supply and every 90 days thereafter as long as the patient continues to receive a prescription for controlled substances. Consultation is also required when prescribing controlled substances for children under the age of two years. In both cases, the consultation must be documented in the patient’s medical record.

APRNs who issue Schedule II prescriptions upon discharge must educate patients regarding the requirement to have the prescription filled at the facility-based pharmacy in order to avoid disruption of care. If a Schedule II prescription is to be filled anywhere outside the hospital facility-based setting, the prescription must be completed by a licensed physician.

In accordance with Section 157.054(a-1) of the Medical Practice Act, a hospital facility-based practice setting does not include free standing clinics—including clinics located on hospital grounds, but not physically attached to the hospital’s main structure—community health centers, or other medical practices associated with or owned and operated by the hospital.

Physicians may delegate authority to APRNs to prescribe Schedule II controlled substances as part of the plan of care for the treatment of a patient who has executed a written certification of terminal illness and has elected to receive hospice care from a qualified hospice provider. The prescriptions for Schedule II drugs issued by the APRN in this situation must be for the purpose of hospice care only. There are no other outpatient settings at which APRNs may prescribe Schedule II controlled substances.

No, the Board cannot assist you with the DEA process. However, you may wish to verify that you and your delegating physician have registered delegation of prescriptive authority with the Texas Medical Board. The DEA verifies delegation of prescriptive authority has been authorized using the Texas Medical Board’s website. If you and the physician have not registered delegation of prescriptive authority, the DEA will not issue your registration until you do so.

We would recommend that you contact the DEA directly to learn what is required to transfer your registration for use in Texas.

We would recommend that you contact the DEA directly to learn what is required to transfer your registration for use in Texas.

Effective March 1, 2020, all APRNs who prescribe opiates, benzodiazepines, barbiturates, or carisoprodol are required to check the prescription monitoring program before prescribing any of these drugs unless the patient has been diagnosed with cancer or sickle cell disease or is receiving hospice care (Texas Health and Safety Code, §§ 481.0764 and 481.0765). The prescriber must clearly note in the prescription record that the patient has been diagnosed with cancer or sickle cell disease or is receiving hospice care.

The answer to the question depends on whether the APRN is issuing a medication order or a prescription drug order. Texas law defines a medication order as an order for administration of a drug [Texas Occupations Code, §551.003(24)]. APRNs are not required to check the prescription monitoring program before writing a medication order for opiates, benzodiazepines, barbiturates, or carisoprodol that will be administered to a patient while the patient is receiving care in the hospital or in an ambulatory surgery center. However, if the APRN issues a prescription drug order to be filled upon discharge from the hospital or ambulatory surgery center, the APRN is responsible for reviewing and documenting the review of the prescription monitoring program and the rationale for prescribing the drug as required by Board Rule 228.2(d). Prescription drug orders are defined as orders to a pharmacist for a drug or device to be dispensed [Texas Occupations Code §551.003(37)].

Yes, provided the prescription is issued for a legitimate medical purpose by an APRN who issues the prescription for a legitimate medical purpose as part of a patient-practitioner relationship as set forth in Texas Occupations Code, §111.005. If an APRN who is licensed to practice in another state plans to provide telemedicine services to a patient located in Texas, the APRN must hold an active Texas APRN license and an active Texas RN license or RN nursing license with multistate privilege from a state that is party to the Nurse Licensure Compact. The APRN must meet all requirements for physician delegation of authority to provide medical aspects of patient care and have a valid prescriptive authority agreement. The APRN must conform to the Texas Nursing Practice Act, Board rules, and all other federal and state laws when providing services in this manner.

The standard of care is the same standard that would apply to the assessment, diagnosis and issuance of the prescription in an in-person setting. The APRN is required to meet the standard of care and demonstrate professional practice standards and judgment consistent with all current laws and rules when providing telemedicine and telehealth services.

Treatment of acute pain with scheduled drugs via telemedicine services is permitted unless otherwise prohibited under federal and state law. APRNs must be aware that acute pain is time limited and refers to the normal, predicted, physiological response to a stimulus, such as trauma, disease, and operative procedures. The APRN must be authorized to prescribe the controlled substance via a valid prescriptive authority agreement with a delegating physician and current DEA registration. APRNs are not permitted to prescribe controlled substances for chronic pain via telemedicine services unless federal or state law expressly permits this practice. Chronic pain is a state in which pain persists beyond the usual course of an acute disease process or healing of an injury and may be associated with a chronic pathological process that causes continuous or intermittent pain over a period of months or years.