Chapter 28 Physician Assistance and the Supervising Physician
PHYSICIAN ASSISTANT (PA) LICENSING, DUTIES, AND RESPONSIBILITIES. 28:2
Definition of a physician assistant 28:2
Education and licensure requirement ………….. 28:2
Degree requirement………….. 28:2
Interim or temporary license.. 28:3
PHYSICIAN ASSISTANT SCOPE OF PRACTICE………….. 28:3
Limits on scope of practice 28:4
PA identification………….. 28:4
Prescriptions…. 28:4
Surgery………… 28:4
Advertising as physician 28:5
PHYSICIAN SUPERVISION RESPONSIBILITIES. 28:5
Requirements of the supervising physician 28:5
Use of protocols 28:5
Board authorization of the supervising physician 28:6
PA examination of patient prior to physician 28:6
Discipline of supervising physician 28:6
OTHER PROCEDURES BY PA………….. 28:7
Physician Assistants in Podiatry………….. 28:7
Acupuncture… 28:7
Laser depilatory 28:7
Orthopaedic PA 28:7
Osteopathic PA 28:8
This chapter contains information on the scope of practice for the physicians assistant and legal ramifications for the supervising physician in Nevada. Although the duties and responsibilities of physicians assistants receive fairly good coverage in the Nevada Revised Statutes, Chapter 630, there are areas of practice as yet undefined by the Nevada legislature or Supreme Court. Further information may be available from the Nevada Board of Medical Examiners which is the governing body of the Physicians Assistant program. The Board may be contacted at PO Box 7238, Reno, NV 89510 or via internet at www.state.nv.us/medical/
PHYSICIAN ASSISTANT LICENSING, DUTIES, AND RESPONSIBILITIES
Definition of a physician assistant
A physicians assistant (PA) is a healthcare professional who, after graduating from an approved program, is qualified to perform medical services under the supervision of a physician and who has been issued a license by the Board._NRS 630.015.
Education and licensure requirements
Nevada requires the PA to graduate from a physician assistant program accredited by the Committee on Allied Health Education and Accreditation or the Commission on Accreditation of Allied Health Education Programs, and requires the PA candidate to pass the National Commission on Certification of Physician Assistants (NCCPA) exam prior to licensure. NRS 630.130; 630.275; NAC 630.290. Generally, the PA is required to be licensed to practice in Nevada, but the PA may get temporary authorization for special circumstances. Licensure of the PA is biennial through the Board of Medical Examiners (the Board). NRS 630.288. The Board determines the regulations concerning licensure. NRS 630.275.
Degree requirement
Before being granted a license, Nevada requires that the PA successfully complete a program of study which has been approved by the American Academy of Physicians Assistants (AAPA). Although the individual programs vary, the typical program requires the applicant to successfully complete two years of college and have some prior healthcare experience. After admission the program generally takes two years to complete. At this time there are no accredited PA programs in Nevada. There are seven programs in California, two in Oregon and one program each in Arizona, Utah, and Idaho. Information on these programs is available via the internet at www.aapa.org/saaapa/index Physician assistants are required to fulfill continuing education requirements and renew licensure every two years.
Interim or temporary license
The Board may issue a temporary license to an applicant who has completed an accredited PA program or is licensed in another state, and is either scheduled for the next available NCCPA exam or has taken the exam and is awaiting the results. The interim licensee may only work under the immediate supervision of a physician. The interim license will be revoked upon failure to take or pass the scheduled exam. NRS 630.130; 630.275; NAC 630.290.
PHYSICIAN ASSISTANT SCOPE OF PRACTICE
Nevada law is vague in defining the PAs scope of practice. The overriding restriction imposed by both the statutes and regulations is that the PA may perform those services delegated to him by the supervising physician. The PA is further restricted to performing those services approved by the Board that are within the scope of his training, experience, and competence. NAC 630.360. More specifically, the American Academy of Physicians Assistants model scope of practice includes:
1) obtaining patient histories and performing physical examinations;
2) ordering and/or performing diagnostic and therapeutic procedures;
- 3) formulating a diagnosis;
4) developing and implementing a treatment plan;
- 4) monitoring the effectiveness of therapeutic interventions;
6) assisting at surgery;
offering counseling and education to meet patient needs; and
8) making appropriate referrals.
Nevada law is more specific regarding prescribing and dispensing of medications by physicians assistants. If the Board approves, the PA may prescribe and dispense controlled and non‑controlled drugs and devices as desired by the supervising physician. The Boards approval is part of the licensure process and is incorporated into the PAs license. The PA is also required to register with the Board of Pharmacy which may certify or deny dispensing privileges independently of the Board of Medical Examiners. NRS 639.1373. Additionally, the Attorney General has issued an opinion that the PA may not possess, administer or dispense any controlled substances or dangerous drugs outside the physical presence of a supervising physician. AGO 201 (3‑10‑1976).
Limits on scope of practice
The PA is specifically prohibited from performing the functions which are limited by law to persons licensed as dentists, chiropractors, podiatrists, and optometrists under chapters 631, 634, 635, and 636 of the Nevada Revised Statutes. Find these on-line at: www.leg.us.nv/nrs
PA identification
The PA is required to wear, while on duty, some form of name tag which identifies him as a PA. The PA must not represent himself in any way which may mislead patients or the general public. Violation of the identification or misrepresentation regulation is grounds for disciplinary action by of the Board. NAC 630.360; 630.380.
Prescriptions
As described above in Scope of Practice, the PA is allowed to prescribe, dispense and administer medications, dangerous drugs and poisons, subject to approval by both the Board of Medical Examiners and the Pharmacy Board. The PA may also request drug samples from pharmaceutical manufacturers or distributors. NRS 639.1373; NAC 639.270-295. The prescription container will bear the name of the practitioner and the certificate under which he is authorized to prescribe. NAC 639.270-295.
Surgery
Under the Nevada regulations, if the supervising physician is allowed to perform surgery as part of his scope of practice, the PA will also be allowed to perform any surgery which is acceptable to the physician and is reasonable in light of the PA’s training, experience, and competence. NRS 630.275; NAC 630.360.
Advertising as a physician
The PA is strictly forbidden to advertise himself as a physician or to mislead either a patient or the public at large as to his title or scope of practice in any manner. Further, since the PA receives licensure in part based on the co-application of the supervising physician, the PA presumably may not advertise independently.
PHYSICIAN SUPERVISION RESPONSIBILITIES
Requirements of the Supervising Physician
Under most circumstances the supervising physician is not required to be physically present for the PA to practice. The physician is required to be available for consultation either directly or by telephone at any time the PA is providing medical care. If the supervising physician is unable to provide this supervision, he may designate an alternate physician with whom the PA may consult. Should the alternate physician be needed to supervise and consult with the PA for a period exceeding three days (72 hours), the supervising physician must get Board approval for the designated alternate.
In addition to ensuring availability for consultation, the supervising physician is responsible for the general oversight of the PA under Nevada law. To satisfy this requirement the physician must perform periodic chart reviews of the PAs patients, and at least once a month must conduct an on-site inspection to monitor the quality of care being provided by the PA. Additionally, the supervising physician must develop and enact a quality assurance program to maintain the standard of care which the PA provides. This program must include assessment of the PAs technical skills, direct observation of the PAs ability to perform a history and physical, and review of documentation procedures. NRS 630.275; NAC 630.370.
Use of protocols
There is no specific statute which addresses the use of protocols for the PA. The great latitude in the scope of practice given to the PA obviates the need to regulate the use of protocols. The AMA and AAPA both recommend avoiding the use of protocols, except in narrowly defined areas of practice such as advanced cardiac life support procedures. The Board does regulate the use of protocols by a collaborating physician and an advanced nurse practitioner. These regulations may be considered as guidelines if the supervising physician should choose to initiate the use of protocols for a PA. These regulations require written parameters which describe the type of procedure to be performed and the location of the facility where the procedure will occur. The Board further requires that the protocol limit the advanced practitioner to performing only the services within their competence and scope of practice. NAC 639.490.
Board authorization of the supervising physician
A supervising physician must apply and receive Board approval prior to working with a PA under his supervision. NRS 630.275; NAC 630.370. Generally a physician may not supervise more than three approved physicians assistants at one time. A physician may petition the Board for permission to expand this number. The Board requires proof that there is a special need for the extra physicians assistants and that the physician will be able to provide adequate supervision for all of his physicians assistants. NAC 630.495.
PA examination of patient prior to physician
Under Nevada law, a PA may examine, diagnose and initiate treatment of a patient without the supervising physician being present. NRS 630.275; NAC 630.360. Medicare guidelines require that for payment for a service which is incident to a physicians service, the physician must initiate the service and provide subsequent services in a manner which reflects the physicians active participation in the treatment. Medicare Carriers Manual 2050.1.
Discipline of supervising physician
Nevada law specifies that a physician may be disciplined by the Board and denied licensure if he knowingly delegates or assigns responsibility for a patient to a person who is not qualified to perform the care. NRS 630.305 (f). There is no case law on the subject, but it would seem that the supervising physician will be held accountable for any unprofessional conduct by the PA.
OTHER PROCEDURES THAT A PHYSICIAN ASSISTANT MAY PERFORM
Because of the broad scope of practice granted by Nevada law, the PA may provide most medical services, limited only by the agreement with, and the scope of practice of, the supervising physician. The PA may triage patients, perform full history and physicals, and provide a diagnosis. The PA may order and evaluate X-rays and other diagnostic tests. The PA may admit or refer the patient to a hospital or long-term care facility. PAs may also initiate procedures they determine necessary to protect or prolong the lives of their patients.
Physician Assistants in Podiatry
There is no direct statutory reference to the use of physicians assistants in the area of podiatry. Under other state models the use of the PA by the podiatrist is limited to situations where the podiatrist is in partnership with a supervising physician who allows the PA to assist the podiatrist.
Acupuncture
The practice of acupuncture is regulated by the Board of Oriental Medicine (BOM) which is separate and independent from the Board of Medical Examiners. As such, neither physicians nor physicians assistants may perform acupuncture without first attending an approved course in oriental medicine and then receiving a license from the Board of Oriental Medicine. Additionally, even if the supervising physician is licensed to practice acupuncture, the PA would need to qualify as an assistant in oriental medicine. This qualification requires completion of a program which is approved by the BOM. NRS 634A.190; 634A.230.
Laser depilatory
There is no specific regulation that prevents the PA from using laser technology in the removal of hair. Generally, the PA will be limited by the scope of practice of the supervising physician and by his own degree of competence. NAC 630.360.
Orthopaedic Physician Assistants
There are no specific regulations pertaining to the practice of orthopaedics by a PA. The practice will be covered by the general requirements that the services provided by the PA be within the supervising physicians scope of practice and within the individual PAs abilities.
Osteopathic Physician Assistants
The Board of Osteopathic Physicians (BOP) also licenses and regulates PAs. The licensing procedure is similar to that of the Board of Medical Examiners. The scope of practice for the osteopathic physicians assistant (OPA) is limited to that of the supervising osteopathic physician. The BOP and the Board of Medical Examiners allow the PA to perform osteopathic services under the supervision of an osteopathic physician. The PA must remain in the employ of the original supervising physician, and the osteopathic physician must be geographically convenient for consultation. There is no reciprocal legislation which allows the OPA to practice medicine under a physicians supervision. NRS 630.274; 633.441; 633.461.