Legal Issue
May 2019 Dallas Medical Journal 21
RISK MANAGEMENT
CONSIDERATIONS
As the healthcare system continues
to adapt to a greater incorporation of
advanced practice providers (APPs),
physicians should get a clear picture
of legal expectations when it comes
to their supervision. Consult your state
medical board for the specific rules
and laws that govern supervising these
employees. APPs include APRNs and
PAs.
Consider the following steps to lower
risks associated with supervising APPs.2
Notify the relevant state board of
your intent to supervise an APP.
For example, a Texas physician should
notify the Texas Medical Board for
a physician assistant and the Texas
Board of Nursing for an advanced
practice registered nurse.
Establish a supervisory agreement
or collaborative care plan.
The plan should detail the working
arrangements between the APP
and the practice, including methods
of communication, scope of
responsibilities, and any other pertinent
Reprinted with permission from
Texas Medical Liability Trust.
Wayne Wenske can be reached at
wayne-wenske@tmlt.org.
details of your working environment or
patient population.
An agreement should be executed,
signed, and dated by the primary
supervising physician and the APP.
Establish written protocols.
Define the role of the APP in detail,
including the main types of cases
that the APP will see, and practice
guidelines, such as limiting the
number of times a patient can see
the APP without seeing a physician,
or specifying the types of injuries or
symptoms that must be examined by a
physician.
Document any delegation of
authority to the APP.
This should include, but not be limited
to, prescriptive authority agreements,
standing delegation orders, standing
medical orders, protocols, or other
practice guidelines.
Solicit patient feedback on APPs.
Regularly ask patients who have had
visits with the APP for any feedback.
Such intermittent checks can help alert
the physician to any issues that could
lower patient satisfaction.
Keep geographic and other
limitations in mind.
Physicians are sometimes required
to supervise APPs at multiple
facilities with some distance between
them. Work out the details of such
arrangements in advance so that
you are satisfied these supervisory
obligations can be met.
Maintain accurate documentation.
In many instances, multiple providers
update or sign off on the same
record, or an office visit may be
primarily covered by an APP with the
physician stopping in for part of the
visit. Providers should make an effort
to document the specific provider
completing each portion of care in the
record to avoid any confusion.
Be available for questions.
A high level of collaboration is
expected between physicians
and APPs. Let the APP know that
whenever they are in doubt, they
should ask questions – and that
there is no such thing as too many
questions. In addition, lawsuits
against APPs and their supervising
physicians frequently cite the failure
of an APP to contact the physician.
An APP should always have reliable
contact information for the supervising
physician.2 DMJ
SOURCES
1. Alli RA. How to read your child’s vital
signs. WebMD Medical Reference, December
2017. Available at https://www.webmd.
com/children/children-vital-signs#1.
Accessed May 17, 2018.
2. Walsh DM, Saucedo JH. Advanced
practice providers: rules, regulations,
and physician supervision. The Reporter.
2015; 24-13. Texas Medical Liability Trust.
Available at https://hub.tmlt. org/reporter/
the-reporter-volume-2-2015. Accessed April
20, 2018.