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Frequently there are issues that arise concerning the scope of services that can be performed by a Physician Assistant (“PA”) and Advanced Registered Nurse Practitioner (“ARNP”). While there is a wealth of existing laws governing PAs and ARNPs there is still some confusion and uncertainty as to what each provider is permitted to do. This article will be limited to a cursory overview of significant provisions as they relate to the supervision requirements of each practice but will suggest some resources that may be helpful should the reader want more information.
As a preliminary matter, the Boards of Medicine and Osteopathic Medicine have the authority to implement rules and discipline as they relate to PAs as they fall under the Medical Practice Act (458.347, Fla. Stat.) and the Osteopathic Medical Practice Act (459.022, Fla. Stat.), ARNPs are governed by the Board of Nursing (464.001, Fla.
Stat.), though some provisions concerning the use of ARNPs do exist under the rules promulgated by the Board of Medicine. Additional regulations are set forth for PAs and ARNPs in chapter 64B8-30, and chapter 64B9-4 of the Florida Administrative Code. ARNPs
In June 2006, Governor Bush signed House Bill 699, which modified aspects of physician supervision of advanced registered nurse practitioners in the office setting. The law essentially limits the numbers of office sites where a physician may supervise ARNPs or PAs. However, there are several exceptions to this law, which do not apply to physicians supervising ARNPs employed in a licensed hospital or ambulatory surgical facility or working in conjunction with a college of medicine or nursing, an accredited graduate medical program or a nursing education program. The level of general physician supervision of ARNPs remains unchanged. The supervising physician must be available either in person or by communication devices, unless the protocol between the ARNP and the physician states otherwise. Under the “Standards for Protocols” in F.A.C. 64B9-4.010, the supervision must be appropriate for prudent health care providers under similar circumstances. ARNPs should remain mindful that the supervising physician is established through the written protocol filed with the Department of Health, which identifies the physician and the delegated medical acts which the ARNP may perform and is signed by both the ARNP and the supervising physician. Additionally, the new law now requires that the protocols must be reviewed by the Board of Nursing, with non-compliant individuals to be referred to the Department of Health.
Under Florida law, an ARNP shall only perform medical acts of diagnosis, treatment and operation pursuant to a protocol between the ARNP and a Florida-licensed medical doctor, osteopathic physician or dentist. The degree and method of supervision is to be determined by both parties and must be specifically identified in the written protocol. More specifically, the protocol should be appropriate for prudent health care providers under similar circumstances and general supervision by the physician or dentist is required, unless otherwise specified. As a rule, ARNPs do not have the authority in Florida to prescribe controlled substances.
In considering an appropriate protocol, Florida law requires a consideration of the following factors: risk to the patient, education, specialty and experience of the parties to the protocol, complexity and risk of the procedures, practice setting and availability of the physician or dentist. Parties to the protocol should consider the specific minimum terms which must be included in each protocol. These terms are fully discussed under 64B8-35.002, F.A.C. Once completed, the original of the protocol and notice must be filed with the Department on an annual basis, with a copy of the notice to be kept at the site of the practice of each party to the protocol. Any changes or amendments to the document must be filed with the Department within thirty (30) days of the alteration. Finally, even after the relationship is terminated, the protocol must be maintained for future purposes for a period of four (4) years.
PAs:
Physician assistants on the other hand, do not require any written protocols unless they are practicing in a health department setting. See 154.04(1) (c), Fla. Stat. On occasion, some insurance companies, hospitals, physicians or other entities may require protocols at their discretion. However, a PA must ensure that a Supervision Data Form is submitted to the Department of Health.
Florida law requires that all records generated by a PA be countersigned by the physician within seven (7) days for the first six (6) months of employment and thereafter no less than every thirty (30) days. Practitioners working in hospitals are urged to ensure that the hospital bylaws do not require countersignature in less time. Keep in mind that PAs cannot make a final diagnosis or interpret x-rays, lab studies or EKGs. The final diagnosis is made when a physician countersigns the medical record.
Under Florida law, a supervising physician shall delegate only tasks and procedures which are within the supervising physician’s scope of practice, or those tasks and procedures which the supervising physician is qualified by training or experience to perform. See 64B8-30.012 F.A.C. Essentially, the decision as to whether a PA may 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 or mortality to the patient. The supervising physician must be certain that the PA is knowledgeable and skilled in performing the tasks and procedures assigned. However, Florida law does identify the following duties as those which are not permitted to be delegated at all, except where otherwise expressly authorized by statute: prescribing, dispensing or compounding medicinal drugs (See 458.347(4) (e) for the exception) and making a final diagnosis.
Additionally, the law identifies the following duties as those which are not to be performed under indirect supervision:
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 EKGs 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 PAs who graduated from Board-approved programs for the education of anesthesiology assistants.
All tasks and procedures performed by the PA must be appropriately documented in the medical record. During the initial six (6) months of supervision of each PA all documentation by the PA in a medical chart must be reviewed, signed and dated by a supervising physician within seven days.
Subsequent thereto, a supervising physician must review, sign and date all documentation by a PA in medical charts within thirty (30) days. In a medical emergency the PA will act in accordance with his or her training and knowledge to maintain life support until a licensed physician assumes responsibility for the patient. Each supervising physician using a PA must remain mindful that he or she is liable for any acts or omissions of the PA acting under the physician’s supervision and control.
See 458.347(15), Fla. Stat.
Under 458.347(3), Fla. Stat., a physician may not supervise more than four (4) currently licensed PAs at any one time.
Important requirement shared by both? Be sure to submit your protocols to the respective Board on an annual basis. Be sure to update these protocols, as needed, and ensure that your professional practice is in compliance with all requirements.
Lastly, it is important not to be lulled into a sense of compliance with the law by simply believing that any person can perform medical services if under direct the supervision of a physician. While there are provisions for medical assistants under the Medical Practice Act, a practitioner must look to his or her own practice to determine if providing such medical services is within the scope of his or her license. An example of this would be a registered nurse providing laser therapy under the supervision of a physician. Would the Board of Medicine permit its delegation or does the Board of Nursing believe that it is inside the scope of a registered nurse’s practice? The answer to both questions is no. As such, we encourage providers to always check with their health care legal counsel prior to providing new services where there may a question as to whether it is appropriate.
The authors encourage readers to read the appropriate rules governing both PAs and ARNPs as well as review profession updates by the respective Boards at their websites. There is helpful information on the websites for the Florida Academy of Physician Assistants and the Florida Nursing Association websites. Additionally, the Florida Board of Medicine website has helpful and useful information.
http://www.fapaonline.org/ http://www.floridanurse.org/ http://www.doh.state.fl.us/MQA/medical/ me_home.html 
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