Risk Management

What may I safely delegate?

ANNE M. MENKE, RN, PhD, OMIC Risk Manager

Young ophthalmologists often join established practices. Non-physician staff at these practices may include licensed team members, such as registered nurses and optometrists, or unlicensed staff, such as technicians and assistants. Young ophthalmologists have called our Hotline worried about over-delegation as well as puzzled when their delegation decisions are seen as risky.

Q Who determines what physicians may delegate?

A What physicians may delegate is part of the “practice of medicine” as defined in each state’s medical practice act and clarified in regulations. Licensed staff have their own legal scope of practice and can contact their licensing board if they are not sure if they may perform certain tasks. Sometimes, even after researching state laws and regulations, you may not be sure of what medical tasks you may delegate to non-physicians. Use the training, licensure/certification process, state law, and the principles discussed in this article to develop protocols that will keep you, your patients, and your staff safe, and improve the defensibility of care rendered under your supervision. Remember the general rule that you may always delegate tasks, but as a physician, you cannot delegate responsibility. The staff members performing tasks on your behalf represent your professional and clinical decisions, and thus, their actions reflect the way you are delivering care to patients.

Q May I delegate prescriptive authority to my staff?

A Yes, but only to certain staff members. Each state limits the ability to write prescriptions to licensed healthcare personnel and provides a “sliding scale” of authority. MDs and DOs are at the top of the scale; with the proper Drug Enforcement Agency (DEA) approval for controlled substances, they have unlimited prescriptive authority to order FDA-approved drugs and devices. All other licensed healthcare providers have restrictions. Physician assistants and nurse practitioners may prescribe only medications normally used by their supervising physician that are also listed in the formulary that comprises part of the standardized protocols directing their actions. In some states, optometrists with special training and licensure have limited prescriptive authority. Unlicensed staff, even if certified, may not prescribe drugs or make any decisions about them.

Q What role may unlicensed staff play in computerized drug order entry systems?

A Physicians in some offices use scribes to document their care and orders and instruct them to enter a medication order into the electronic medical record or drug order entry system. In offices with no physician assistant or nurse practitioner, only an ophthalmologist may prescribe drugs or direct a scribe to enter an oral order into the medical record or computerized physician order entry system. The physician must clearly specify the drug and dosage and is responsible for the appropriateness and accuracy of the “scribed” order. To ensure patient safety and limit liability risk, staff should be instructed to read back each order.

Q Who may determine if a patient is a candidate for a cosmetic medical procedure? Who may perform the procedure?

A It takes considerable knowledge and judgment to determine the cause of presenting complaints, what treatment is indicated, if any, and whether the findings from the patient’s history or examination signal increased risk or constitute contraindications. In other words, assessing patients to determine candidacy is the practice of medicine. Nearly all states have legal mechanisms for registered nurses to perform tasks that are considered the practice of medicine, such as Botox injections and some types of laser surgery. With sufficient training and the appropriate standardized protocols that delineate indications, contraindications, treatments, and consultation requirements, registered nurses may usually elicit the history, perform the initial examination, and discuss a proposed course of treatment with the patient as a prelude to presenting their recommendations to the supervising physician. If the physician approves the patient’s candidacy and orders the treatment or series of treatments, the registered nurse may implement the order. Unlicensed staff, even if certified, may not determine candidacy. Contact OMIC’s confidential Risk Management Hotline to determine if you may delegate cosmetic medical procedures to unlicensed staff.