Texas enforces a delegated practice model that shapes how nurse practitioners deliver care across the state. Under healthcare law, nurse practitioners in Texas must operate within a framework of physician delegation and documented prescriptive authority. That means a nurse practitioner must hold an active license and work under a written Prescriptive Authority Agreement when performing advanced clinical acts or prescribing medication.
The Texas Board of Nursing (BON) issues and enforces licensing standards, while the Texas Medical Board (TMB) governs the delegation of medical acts and the registration of prescriptive authority. This structure affects daily workflows, clinic staffing, and compliance responsibilities. Supervising physicians assume legal responsibility for delegated acts and must be accessible for consultation, review a sample of charts, and document supervisory activities.
For NPs, understanding the limits and conditions of their NP practice authority is essential to safe patient care and to avoid regulatory penalties. This guide explains the core rules for PAAs, supervision expectations, chart review practices, controlled substance limits, and practical steps clinics should take to maintain compliance under current Texas law.
Core Concept: Physician Delegation and Prescriptive Authority Agreements (PAA)
Texas law requires delegation for advanced clinical acts that go beyond basic RN practice. For prescribing medications and ordering certain medical treatments, the formal mechanism is a Prescriptive Authority Agreement, commonly called a PAA. A PAA is a written, dated, and signed agreement between a physician and an APRN that states the delegated scope, site locations, and the supervisory plan. The physician who signs the PAA is the supervising physician and assumes responsibility for the delegated medical acts. State law requires that a PAA and any amendments be reviewed at least once a year and be made available to regulators on request.
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Key Requirements of the Prescriptive Authority Agreement (PAA)
A. Eligibility Requirements
The nurse practitioner must hold a current nurse practitioner license in Texas and meet any additional BON criteria for APRN practice. The supervising physician must hold an active, unrestricted Texas medical license and generally have a specialty that matches the area of delegated practice.
B. Scope and Site Requirements
A PAA must be site-based. Delegation may apply only at practice locations where the physician actively practices. The PAA must clearly specify sites and the scope of delegated activities. An NP’s scope under the agreement must align with the NP’s education, training, and demonstrated competence. The agreement should specify any limitations on drug categories or clinical acts.
C. Supervisory Responsibilities and Physician Availability
Supervision is not defined as constant presence. The law focuses on appropriate supervision based on patient acuity and the NP’s experience. The PAA must describe how the physician will be available for consultation, referral, and emergencies. Many practices set clear expectations in the PAA for periodic on-site visits, scheduled case reviews, and availability by phone or electronic means. Parties should document how supervision will be provided in daily practice.
D. Chart Review and Documentation
The parties to a PAA determine chart review frequency and sample sizes based on practice risk and setting. Texas law does not mandate a specific percentage. It does require that chart review practices be reasonable and documented. Many organizations use structured sampling to focus on complex patients or high-risk prescribing. Maintain records of chart review findings and any corrective actions.
E. Review and Retention Requirements
A PAA must be reviewed and signed at least annually. The agreement and any amendments must be made available to the Texas Board of Nursing and the Texas Medical Board on request, typically within three business days. Keep original signed documents at the practice site and maintain logs of supervisory activities.
Restrictions and Common Limits
- No Independent Practice: Nurse practitioners in Texas must work under a licensed physician’s supervision through a valid Prescriptive Authority Agreement (PAA). Independent practice is not permitted under current law.
- Supervision Ratio: A supervising physician can oversee no more than four nurse practitioners at one time, guaranteeing that oversight remains manageable and compliant with Texas Medical Board standards.
- On-Site Visits Required: Supervision cannot be entirely remote. The physician must conduct regular, in-person visits, typically once a month, to review patient charts, evaluate workflow, and confirm compliance with the PAA.
- Controlled Substance Restrictions: Nurse practitioners can prescribe only Schedules III–V controlled substances. Schedule II prescriptions are restricted to specific settings, such as hospitals, hospice, or palliative care facilities.
- Scope of Practice Alignment: All delegated medical tasks must align with the NP’s training, education, and certification, as well as the supervising physician’s area of practice.
- No Solo Practice Ownership: NPs cannot open or operate a solo medical practice without a supervising physician, as all delegated acts must fall within the terms of the physician’s delegation agreement.
- Documentation and Recordkeeping: The PAA must be reviewed and signed annually, and records of chart reviews, site visits, and supervision logs must be maintained for inspection by the Texas Nursing Board or Texas Medical Board.
- Legal Accountability: Both the NP and supervising physician share responsibility for maintaining compliance with Texas healthcare law, guaranteeing safe, lawful, and high-quality patient care.
Practical Steps for Practices
- Use a complete, signed PAA template that lists parties, sites, license numbers, scope of delegation, and supervision methods. Keep signed originals on file.
- Register delegated prescriptive authority with the Texas Medical Board promptly after execution.
- Define a chart review plan and document findings with remediation steps when needed.
- Verify the APRN holds an active nurse practitioner license in Texas prior to patient care, and confirm DEA registration when controlled substance prescribing will occur.
- Assign a compliance owner who tracks renewals, registrations, and audit schedules.
Conclusion
Texas operates a delegated practice model that centers on written prescriptive authority agreements and active supervision by physicians. The Texas Board of Nursing and Texas Medical Board share oversight roles that require a PAA to be site-specific, reviewed annually, and available for inspection. Chart review practices and supervision intensity must fit the clinical setting and patient risk, and delegation for Schedule II prescribing is highly constrained.
Staying compliant means documenting agreements, registering delegated authority with the TMB, verifying licensure, and maintaining a routine audit process. Understanding and following Texas healthcare law is essential for nurse practitioners and physicians alike, as it guarantees that all supervisory agreements, prescriptive practices, and patient care activities remain compliant and legally sound.
For nurse practitioners or physicians exploring opportunities for expansion or buying a medical practice, Strategic Medical Brokers offers expert insight to help guarantee every partnership or acquisition aligns with Texas healthcare regulations. Talk to us to learn more!
