Introduction to Prescriptive Authority

by Amy Howells, PhD, CPNP-AC/PC

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    00:00 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.

    00:14 This authority is integral to clinical practice as it allows APRNs to provide comprehensive care.

    00:21 This includes initiation, management, and cessation of medication therapy.

    00:26 The scope of this authority can vary widely between different regions and is governed by state laws and professional licensing boards.

    00:34 It gets a little confusing.

    00:36 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.

    00:45 The first physician assistants and nurse practitioners were granted advanced medical licensure and rights to prescribe specific medications, including controlled substances.

    00:57 Conceptually speaking, physicians of either doctor of medicine or doctor of osteopathic medicine designations they have the highest degree of prescriptive authority.

    01:07 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.

    01:22 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.

    01:35 They are put into the category of something that needs a prescription.

    01:39 This includes controlled substances, which are further classified into scheduled classes based on the potential for misuse.

    01:46 Persons with advanced medical academic training and licensure have the authority to prescribe these medications, which includes physicians, PAs and APRNs.

    01:59 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.

    02:12 There are some states that have full practice authority.

    02:15 In these states, APRNs can evaluate patients.

    02:18 They can diagnose conditions and prescribe appropriate treatments independently, which increases healthcare accessibility, especially in those underserved areas.

    02:28 States that have restricted or reduced practice authority and participate in a collaborative or an integrated care practice.

    02:36 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.

    02:51 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.

    03:06 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.

    03:21 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.

    03:32 So that is where the confusion can come from.

    03:35 Each state has different laws about collaborative agreements between APRNs and supervising physicians.

    03:41 So in the US, the oversight is different from state to state.

    03:45 The Drug Enforcement Administration is the federal agency enacting the Controlled Substances Act.

    03:52 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.

    04:15 Your documentation of meeting examination standards.

    04:19 How do you achieve prescriptive authority, especially with all of this craziness? First, you must complete a credentialed and accredited academic program.

    04:28 Second, you must achieve a passing score.

    04:31 That goes without saying.

    04:33 And remember, there are lots of different kinds of APRNs.

    04:37 Third, get ready for a ton of paperwork.

    04:41 Every state's paperwork is a little bit different depending on whether you are eligible to apply for a single or multistate licensure.

    04:48 Whether the state is a full practice authority versus a collaborative agreement state also matters.

    04:54 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.

    05:05 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.

    05:20 This will mean having a working relationship with that agency.

    05:24 In order to prescribe controlled substances, you will also need to submit an application for a federal DEA licensure.

    05:32 You guessed it, more paperwork.

    05:35 Some extra details on holding a DEA license to think about.

    05:40 Be prepared that obtaining a DEA license involves meeting their criteria, completing the process, and of course, paying additional fees.

    05:50 You will be expected to have working familiarity with the controlled substances schedules I-V and implications for prescribing those substances.

    06:00 Once you have a DEA license, you and your agency will be expected to maintain records and submit to DEA audits.

    06:08 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.

    06:31 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.

    06:43 so it's not foolproof, but it may prevent doctor script shopping.

    06:47 Be aware of risk evaluation and mitigation protocols published by the FDA.

    06:52 Get on their email listserv.

    06:55 This way you can stay current on all of those high risk warnings about drug concerns.

    06:59 Did you think we forgot about actually writing a prescription? Like any other aspect of healthcare quality, documentation is super important.

    07:10 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.

    07:22 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.

    07:34 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.

    07:47 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.

    07:59 Whew. That's a lot, but we have to have all of that on our prescriptions.

    08:04 Some other things to consider when regularly writing prescriptions.

    08:08 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.

    08:19 But try to avoid being dependent on these systems.

    08:22 They're not completely fail safe.

    08:25 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.

    08:39 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.

    08:56 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.

    09:09 These you can manually enter.

    09:11 Typically, a drop down feature will appear.

    09:14 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.

    09:22 So that covers the very basics of prescriptive authority.

    09:26 Really just the basics.

    09:27 There is so much more to this topic to learn, but this should get you started.

    09:31 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.

    09:54 Really? We're not kidding. You need to stay current.

    09:57 Yes, there is the paperwork side of things to maintain your practice license, your authority licensure, your clinical privileges, and your DEA licensure.

    10:06 Remember, each will have their own timeline and their own CEU requirements and their own fees.

    10:12 So you have to be organized about this.

    10:14 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.

    About the Lecture

    The lecture Introduction to Prescriptive Authority by Amy Howells, PhD, CPNP-AC/PC is from the course Role Transitions (APRN).

    Included Quiz Questions

    1. Registered Nurses
    2. Nurse Practitioners
    3. Physician Assistants
    4. Medical Doctors
    5. Doctors of Osteopathy
    1. Lower rates of hospital admission
    2. Frequent trips to the emergency department
    3. Increased hospital readmission rates
    4. Slower time to treatment or intervention
    5. Worse outcomes, particularly in rural settings
    1. Complete 500 supervised clinical hours
    2. Complete a credentialed and accredited academic program
    3. Achieve a passing score on licensure exam
    4. Complete practice-state specific paperwork
    5. Submit an application for DEA licensure
    1. Prescriptive authority oversight varies significantly from state to state.
    2. The Federal Drug Administration (DEA) is the only regulatory agency in charge of prescriptive authority for APRNs.
    3. The examination licensing group oversees an APRN's clinical practice, not prescriptive authority.
    4. The examination licensing group oversees the prescription of controlled substances.
    5. APRNs have been granted full prescriptive authority autonomy in all states.
    1. An APRN attends continuing education conferences regularly to stay current on the latest pharmacologic management guidelines.
    2. An APRN relies on their employer to remind them when it is time to renew their DEA licensure paperwork.
    3. An APRN follows the prescribing practices of their collaborating physician even though it does not align with the latest practice guidelines.
    4. An APRN relies solely on the electronic health record to inform them of medication interactions.
    5. An APRN prescribes high doses of opioid medications to ensure positive patient reviews.

    Author of lecture Introduction to Prescriptive Authority

     Amy Howells, PhD, CPNP-AC/PC

    Amy Howells, PhD, CPNP-AC/PC

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