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Oklahoma Board of Medical Licensure and Supervision
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ISSUES and ANSWERS

Vol 10 No 1
March 1999

Supervising Advanced Practice Nurses with Prescriptive Authority

by Gerald C. Zumwalt, M.D.
Board Secretary/Medical Advisor

There are markedly parallel rules for supervision of APNs and Physicians Assistants with prescriptive authority. One notable difference is that this Board does not have prior notification nor approval of the supervising agreement between physicians and APNs. Advanced Practice Nurses are regulated by the Oklahoma State Board of Nursing and the supervisory agreements are issued by that group. Our Board periodically does review the list of doctors supervising this group of nurses. It is, therefore, the positive responsibility of the MD agreeing to be the APN's supervisor to be sure that he/she meets the rules (OAC 435:10-13-2). Failure to meet and maintain these requirements constitutes unprofessional conduct.

Although previously published, we are reprinting the rule at this time.

OAC 435:10-13-2. Eligibility to supervise advanced practice nurse with prescriptive authority

(a) To be eligible to serve as supervising physician for the advanced practice nurse with prescriptive authority, an allopathic physician shall meet the following criteria:

(1) Have possession of a full and unrestricted Oklahoma medical license with Drug Enforcement Agency (DEA) and Oklahoma Bureau of Narcotics (OBN) permits for any drug on the formulary as defined in the Oklahoma Nursing Practice Act.

(2) The physician shall be in an active clinical practice in which no less than twenty (20) hours per week shall involve direct patient contact.

(3) The supervising physician shall be trained and fully qualified in the field of the advanced practice nurse's specialty.

(4) No physician shall supervise more than two (2) full time equivalent advanced practice nurses regarding their prescriptive authority at any one time. For purposes of this section, each "full time equivalent" advanced practice nurse position equals forty (40) hours per week collectively worked by the part-time advanced practice nurses being supervised by the physician. Notwithstanding the provisions for the supervision of two (2) full time equivalent advanced practice nurses above, no physician shall supervise more than a total of four (4) advanced practice nurses. The Board may make an exception to any limit set herein upon request by the physician.

(b) Proper physician supervision of the advanced practice nurse with prescriptive authority is essential. The supervising physician should regularly and routinely review the prescriptive practices and patterns of the advanced practice nurse with prescriptive authority. Supervision implies that there is appropriate referral, consultation, and collaboration between the advanced practice nurse and the supervising physician.

"Supervision implies that there is appropriate referral, consultation, and collaboration between the advanced practice nurse and the supervising physician."


Figure 1.

Physician Assistants Drug Formulary Excluded Drugs
November 1998

Anti-Infective Agents:

1. Chloramphenicol

2. Pediatric Quinolones

3. Pediatric tetracyclines

Autonomic Agents:

1. Any preparation containing a Scheduled II CDS

Central Nervous System Agents:

1. Schedule I or II opiate agonists

2. Schedule I or II opiate partial agonists

3. Opiate antagonists

Expectorants, Antitussives and Mucolytic Agents:

1. Any preparation containing a Schedule II CDS

Eye, Ear, Nose and Throat Preparations:

1. Any preparation containing a Schedule II CDS

2. Steroid _ containing ophthalmic preparations

3. Carbonic Anhydrase inhibitors

4. Opthalmic anesthetics

5. Miotics

6. Mydriatics

7. Misc. EENT drugs

(Ref: American Hospital Formulary Service 52:36)

Gastrointestinal agents:

1. Any preparation containing a Schedule II CDS

Hormone and Synthetic Substitutes:

1. Androgens

2. Antithyroid agents

3. Parathyroid hormones and synthetics

4. Pituitary hormones and synthetics

Oxytocics:

All agents are excluded under the oxytocics category

Skin and Mucous Membrane agents:

1. Cell stimulants and proliferants

2. Keratolytic agents

3. Kerotoplastic agents

4. Misc. Agents (Ref: American Hospital Formulary Service 84:36)

5. Depigmenting and pigmenting agents


The following information was compiled by Bryan Potter, Director of the Oklahoma Board of Pharmacy. Additional articles will be run as more regulations are established by OBN, DEA and other controlling bodies.

Prescribing in Oklahoma

Physician Assistants, as of November 1, 1998, have prescribing authority as set out by their supervising physicians. Up until that time they had been authorized to write prescriptions or orders for the physician and technically could not prescribe. Now they may obtain a mid-level DEA number to prescribe CDS, Schedules III, IV and V. Prescriptions for CDS are limited to 40 dosage units with only (1) refill or a 10 day supply maximum (whichever is smaller). Non-controlled drugs are limited to a 34 day supply with (2) refills of a drug prescribed for the first time for the patient. A 90-day supply or 100 dosage units (whichever is greater) of drugs prescribed for chronic, stable conditions, may be prescribed. P.A.s have a Formulary that excludes certain drug categories. (See figure 1) The name of the physician will be placed on the prescription label with a slash/P.A. (Dr. Jones/PA)

Advance Practice Nurses are authorized by the Board of Nursing to prescribe as Advanced Registered Nurse Practitioners, Clinical Nurse Specialists, or Certified Nurse Midwifes subject to the medical direction of a supervising physician. They have prescribing authority and may obtain a mid-level DEA number to prescribe CDS, Schedules III, IV and V, limited to a seven day supply. The nurses have an Exclusionary Formulary — a list of drugs they cannot prescribe. (See figure 2) The name of the Advance Practice Nurse will be placed on the prescription label.

A Certified Registered Nurse Anesthetist may order, select, obtain and administer drugs in Schedule II, III, IV and V only in the peri-operative or peri-obstetrical period. CRNAs cannot write outpatient prescriptions.

Optometrists have prescribing authority and may obtain a mid-level DEA number for prescribing CDS, Schedules III, IV and V, limited to a seven-day supply and no refills. Drugs prescribed have to be for abnormalities of the eye.

Optometrists, Advance Practice Nurses and Physician Assistants may receive and distribute drug samples. The sample drug must be a drug they can prescribe.

The legislators included language in the statutes of the professions listed above to require their prescriptions to be filled by a pharmacist for added protection for the patients. Pharmacists are responsible for the dosage and drug utilization review.

There is a great opportunity to work with these health professionals and share your drug knowledge for the benefit of the patient.


Oklahoma State Bureau of Narcotics and Dangerous Drugs Control

OAC 475:30-1-3. Purpose of issuance of prescriptions

. . .

(b) A prescription may not be issued in order for a registered or otherwise authorized individual practitioner to obtain controlled dangerous substances to stock or resupply his/her office or medical bag for the purpose of general dispensing to patients.

(c) A prescription may not be issued for the dispensing of a controlled dangerous substance listed in any schedule to a drug dependent person for the purpose of continuing his/her dependence upon such drugs.

(d) A practitioner may not distribute, dispense, sell, give, prescribe or administer any controlled substances in Schedules I through V for the practitioner's personal use, or for an immediate family member. Provided that this paragraph shall not apply to family members outside the second degree of consanguinity or affinity. Provided further that this paragraph shall not apply to medical emergencies when no other medical doctor is available to respond to the emergency.

For a complete copy of prescribing rules contact the OBN at (405) 521-2885 and the Pharmacy Board at (405) 521-3815

Guidelines for Prescription Blanks

Figure 2.

Advanced Practice Nurses with Prescriptive Authority

Exclusionary Formulary

Reference for the Exclusionary Formulary

American Hospital Formulary Drug

Information 96

AHFS Pharmacologic _ Therapeutic Classification

The Exclusionary Formulary includes:

28:04 Anesthetics, General

A. Barbiturates

1. Sodium Thiopental (Pentothal)

2. Sodium Methohexital (Brevital)

3. Sodium Thiamylal (Surital)

B. Nonbarbiturates

1. Ketamine (Ketalar)

2. Etomidate (Amidate)

3. Midozolam (Versed)

4. Propofol (Diprivan)

5. Fentanyl/Droperidol (Innovar)

6. Morphine Sulfate & Atropine

7. Meperidine & Atropine

8. Doperidol (Inapsine)

C. Gases

1. Nitrous Oxide

2. Cyclopropane

3. Ethylene

D. Volatile Liquids

1. Sevoflurane (Ultane)

2. Desflurane (Suprane)

3. Enflurane (Ethrane)

4. Isoflurane (Forane)

5. Methoxyflurane (Penthrane)

6. Halothane (Fluothane)

E. Narcotics (All Schedule II CDS excluded)

1. Morphine Sulfate

2. Meperidine

3. Fentanyl

4. Sufentanil

5. Alfentanil

28:08 Analgesics (Schedule I & II)

60:00 Gold Compounds

78:00 Radioactive Agents


Board Meeting —

January 21, 22, 1999

The Oklahoma State Board of Medical Licensure and Supervision met in regularly scheduled session on Thursday and Friday, January 21, 22, 1999. During this period three full licenses and one special license were issued after personal appearances by the applicants. Two applications were denied. One due to history of substance abuse and false information on the application and one due to history of disruptive behavior.

Three special purpose licenses were modified, one to allow practice in a different geographical location, one to allow use of controlled substances post-surgically and limited to hospital patients, and one to allow use of controlled substances in nursing home and hospital patients.

The first application by a doctor to supervise more than two full-time equivalent advanced practice nurses with prescriptive authority was denied.

Disciplinary hearing results included one revocation for multiple cases of medical mismanagement and two Voluntary Submittals to Jurisdiction that imposed probation for personal substance abuse. One Voluntary Submittal to Jurisdiction was adopted imposing terms of six months of suspension, mandatory evaluation and five years of probation as a result of sexual misconduct and violation of narcotic prescription laws. One case was continued with an agreement that the licensee would prescribe no controlled drugs until the case was heard by the Board.


Results of What Would You Do?

December 1998

Concerning the doctor who had violated his probation by continuing narcotic abuse, then disappeared without notifying the Board only to reappear in six months after undergoing drug rehabilitation and affiliating with a church:

The Board reinstated his license with standard terms of probation including no self prescribing of any medication, abstaining from mood-altering medications and keeping duplicate copies of all prescriptions written. A warning that any new violation of the Medical Practice Act would result in automatic revocation was attached.