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What is prescriptive authority?
Prescriptive authority refers
to the legal permission
granted to qualified
advanced practitioners,
such as nurse practitioners,
to prescribe medications, therapies,
and other treatment modalities.
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This authority is integral
to clinical practice
as it allows APRNs to provide
comprehensive care.
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This includes initiation, management,
and cessation of medication therapy.
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The scope of this authority can
vary widely between different regions
and is governed by state laws and
professional licensing boards.
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It gets a little confusing.
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How did this all start?
The term prescriptive authority
is thrown around a lot these days,
but the idea has been around
since the early 1960s.
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The first physician assistants
and nurse practitioners
were granted advanced
medical licensure
and rights to prescribe
specific medications,
including controlled substances.
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Conceptually speaking,
physicians of either doctor of medicine
or doctor of osteopathic
medicine designations
they have the highest degree
of prescriptive authority.
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Other healthcare providers,
PA and APRM providers
have varying degrees of autonomy
to prescribe medications,
but they may undergo physician
supervision or delegation
depending on
individual state laws.
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So what falls under these prescribed
medications and treatments?
Very simply stated, medications that
are considered to be potentially harmful
if not used under the supervision
of a licensed healthcare practitioner.
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They are put into the category of
something that needs a prescription.
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This includes controlled substances,
which are further classified
into scheduled classes
based on the
potential for misuse.
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Persons with advanced medical
academic training and licensure
have the authority to
prescribe these medications,
which includes
physicians, PAs and APRNs.
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So how does the scope of prescriptive
authority work for the APRN?
Well, there isn't a
simple answer to this one,
but in the US it generally falls into
two approaches at the state level.
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There are some states that
have full practice authority.
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In these states,
APRNs can evaluate patients.
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They can diagnose conditions
and prescribe appropriate
treatments independently,
which increases healthcare accessibility,
especially in those underserved areas.
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States that have restricted
or reduced practice authority
and participate in a collaborative
or an integrated care practice.
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In these states,
APRNs with prescriptive authority
have to work within a
collaborative or practice agreement
with a medical physician,
and that physician
would provide oversight
to the prescriptive portion of
their advanced medical practice.
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So why is prescriptive authority
so important for the APRN?
Having this authority to prescribe
can lead to quicker interventions,
which research has shown
improves patient outcomes,
especially in outpatient
and rural settings.
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Patients cared for by APRNs
with prescriptive authority
had lower rates of hospital
admissions readmissions,
and they used less inappropriate
emergency services,
and this increases
healthcare efficiency.
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Who provides prescriptive
authority oversight?
In the US, oversight comes
from the state, federal
and from the professional licensing
agencies, all at the same time.
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So that is where the
confusion can come from.
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Each state has different laws
about collaborative agreements
between APRNs and
supervising physicians.
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So in the US, the oversight
is different from state to state.
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The Drug Enforcement Administration
is the federal agency
enacting the Controlled
Substances Act.
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They are the agency overseeing
prescriptions of controlled substances,
the examination licensing group,
whether that is the
ANCC, the AACN, the NCC,
any other Alphabet
soup you can think of
is also part of the
prescriptive authority process
as they provide a crucial part of
the prescriptive authority paperwork.
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Your documentation of
meeting examination standards.
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How do you achieve prescriptive authority,
especially with all of this craziness?
First, you must complete a credentialed
and accredited academic program.
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Second, you must achieve a passing
score.
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That goes without saying.
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And remember, there are lots
of different kinds of APRNs.
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Third, get ready for
a ton of paperwork.
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Every state's paperwork
is a little bit different
depending on whether you
are eligible to apply
for a single or
multistate licensure.
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Whether the state is
a full practice authority
versus a collaborative
agreement state also matters.
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Got all that so far?
Some states may have you apply
for both your practice license
and your prescriptive
authority license concurrently,
especially for the first application.
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Now that you have your APRN license,
what do you do next?
Once you have your practice license and
your prescriptive authority license,
most states will also ask you
to have your clinical privileges
at a healthcare facility in your region.
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This will mean having a working
relationship with that agency.
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In order to prescribe
controlled substances,
you will also need to submit an
application for a federal DEA licensure.
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You guessed it, more paperwork.
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Some extra details on holding
a DEA license to think about.
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Be prepared that obtaining a DEA
license involves meeting their criteria,
completing the process, and of course,
paying additional fees.
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You will be expected to
have working familiarity
with the controlled
substances schedules I-V
and implications for
prescribing those substances.
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Once you have a DEA license,
you and your agency will be expected to
maintain records and submit to DEA audits.
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You will need a DEA license for
every state that you practice in,
and the CEU requirements regularly change.
Still got all of that?
Well, within that environment, you have
to have ways to protect your license
and your prescriptive
authority privileges
because it can be somewhat easy
to miss some of that paperwork.
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Seeing CEU requirements
for what they are,
which are ways to stay current
in participating in prescription
drug monitoring programs,
lets you check the individual's
patterns of use before prescribing.
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so it's not foolproof, but it may
prevent doctor script shopping.
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Be aware of risk evaluation and
mitigation protocols published by the FDA.
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Get on their email listserv.
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This way you can stay current
on all of those high risk
warnings about drug concerns.
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Did you think we forgot about
actually writing a prescription?
Like any other aspect of healthcare
quality, documentation is super important.
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In addition to the
actual prescription,
you will be expected to reference
your plans regarding pharmacologic
and non-pharmacologic
treatments and interventions
that you order throughout
the medical record.
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Your academic training
should prepare you
for what the actual medication
prescription should include,
but let's review on a paper prescription
pad image to make sure you have it.
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On a paper prescription pad,
you're going to have patient name
a unique identifier,
your DEA number,
especially if it's a controlled
substance that you're prescribing.
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Your name and credentials,
the date of the prescription
name and strength of the drug,
how much you want dispensed,
duration and the number
of refills allowed.
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Whew. That's a lot, but we have to
have all of that on our prescriptions.
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Some other things to consider when
regularly writing prescriptions.
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So how do you avoid mistakes?
EHRs can be great.
They have embedded flag systems
that will alert you to out of range
doses, allergies, or interactions.
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But try to avoid being
dependent on these systems.
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They're not
completely fail safe.
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Anticipate that each state or
facility may have different policies
on how many refills a particular
drug or class can be filled
and what documentation you
may need to complete to do so
for it to be covered
by insurance.
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So what about in an electronic
health record format?
In an EHR,
this may look a little different
because many of the fields
will auto populate
if you're logged into
your unique profile,
an electronic healthcare system
where you have clinical privileges.
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These will probably
pop up automatically
when you enter the pharmacy
prescription prompts
patient name unique identifier,
DEA, your name and credentials
and date of the prescription.
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These you can manually enter.
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Typically,
a drop down feature will appear.
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Be careful that you
choose the correct one,
the name and strength of the
drug, how much is dispensed,
duration and number
of refills allowed.
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So that covers the very basics
of prescriptive authority.
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Really just the basics.
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There is so much more to this topic to
learn, but this should get you started.
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In addition to knowing that
there are big differences
between states and what
rules aPRNs must follow
regarding prescriptive
authority,
what oversight it involves,
and the structure of a prescription,
the most important obligation you have
is to stay current, stay
current, and stay current.
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Really? We're not kidding.
You need to stay current.
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Yes, there is the paperwork side of
things to maintain your practice license,
your authority licensure, your clinical
privileges, and your DEA licensure.
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Remember,
each will have their own timeline
and their own CEU requirements
and their own fees.
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So you have to be
organized about this.
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But ethically, you are responsible
for staying informed about new drugs,
prescribing guidelines,
and being a responsible provider,
especially for high risk
medications like opioids.