The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

1. (1) Advanced health assessment course--A course that offers content supported by related clinical experience such that students gain the knowledge and skills needed to perform comprehensive assessments, including histories and physical examinations, to make diagnoses and formulate effective clinical management plans.
2. (2) Advanced pathophysiology course--A course that offers content that provides a comprehensive, systems-based study of pathophysiology that provides students with the knowledge and skills to analyze the relationship between normal physiology and pathophysiological phenomena.
3. (3) Advanced pharmacotherapeutics course--A course that offers advanced content in pharmacokinetics and pharmacodynamics, encompassing a broad range of drug classifications, including the application of drug therapy to the treatment of disease and/or the promotion of health.

4. (4) Advanced practice registered nurse--A registered nurse who:

   1. (A) has completed a graduate-level education program accredited by an organization recognized by the Board that prepares him/her for one of the four following recognized advanced practice roles:

      1. (i) nurse anesthetist,
      2. (ii) nurse-midwife,
      3. (iii) nurse practitioner; or
      4. (iv) clinical nurse specialist;

   2. (B) has demonstrated current competence by:

      1. (i) passing a national certification examination recognized by the Board that measures advanced practice role and population-focused competencies and demonstrating continuing competence as evidenced by certification maintenance/recertification in the role and population through a national certification program; or
      2. (ii) meeting requirements set forth by the Board for those advanced practice registered nurses not required by §221.7 of this title (relating to Petitions for Waiver and Exemptions) to hold national certification;
   3. (C) has acquired advanced clinical knowledge and skills preparing him/her to provide direct and indirect care to patients with greater role autonomy;
   4. (D) has been educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems that includes the use and prescription of pharmacologic and non-pharmacologic interventions;
   5. (E) has clinical experiences of sufficient depth and breadth to reflect the area of licensure; and
   6. (F) holds current licensure in one of the four advanced practice roles and a Board-approved population focus area.

5. (5) Alternate site--A practice site:

   1. (A) where the services provided are similar to the services provided at the delegating physician's primary practice site; and
   2. (B) located within 75 miles of the delegating physician's residence or primary practice site.
6. (6) Board--The Texas Board of Nursing.
7. (7) Controlled substance--A substance, including a drug, an adulterant, and a dilutant, listed in Schedules I through V or Penalty Groups 1, 1-A, or 2 through 4 of chapter 481 Texas Health and Safety Code (Texas Controlled Substances Act). The term includes the aggregate weight of any mixture, solution, or other substance containing a controlled substance.
8. (8) Dangerous drug--A device or a drug that is unsafe for self medication and that is not included in schedules I-V or penalty groups I-IV of chapter 481 Texas Health and Safety Code (Texas Controlled Substances Act). The term includes a device or a drug that bears or is required to bear the legend: "Caution: federal law prohibits dispensing without prescription" or "RX only" or another legend that complies with federal law.
9. (9) Diagnosis and management course--A course offering both didactic and clinical content in clinical decision-making and aspects of medical diagnosis and medical management of diseases and conditions. Supervised clinical practice must include the opportunity to provide pharmacological and non-pharmacological management of diseases and conditions considered within the scope of practice of the advanced practice registered nurse's population focus area and role.
10. (10) Eligible sites--Sites serving medically underserved populations; a physician's primary practice site; an alternate site; or a facility-based practice site.
11. (11) Facility-based practice site--A licensed hospital or licensed long term care facility that serves as the practice location for the advanced practice registered nurse.
12. (12) Health Manpower Shortage Area--An urban or rural area, population group, or public or nonprofit private medical facility or other facility that the Secretary of the United States Department of Health and Human Services (USDHHS) designates as having a health manpower shortage, as described by 42 USC Section 254e(a)(1) or a successor federal statute or regulation.

13. (13) Medically Underserved Area (MUA)--

    1. (A) An urban or rural area or population group that the Secretary of the United States Department of Health and Human Services (USDHHS) designates as having a shortage of those services as described by 42 USC Section 300e-1(7) or a successor federal statute or regulation; or
    2. (B) an area defined as medically underserved by rules adopted by the Texas Department of State Health Services based on demographics specific to this state, geographic factors that affect access to health care, and environmental health factors.

14. (14) Physician's primary practice site--

    1. (A) the practice location at which the physician spends the majority of his/her time;
    2. (B) a licensed hospital, a licensed long-term care facility, or a licensed adult care center where both the physician and the advanced practice registered nurse are authorized to practice;
    3. (C) a clinic operated by or for the benefit of a public school district to provide care to the students of that district and the siblings of those students, if consent to treatment at that clinic is obtained in a manner that complies with Chapter 32, Family Code;
    4. (D) the residence of an established patient;
    5. (E) another location at which the physician is physically present with the advanced practice registered nurse; and

    6. (F) provided an advanced practice registered nurse spends at least 50 percent of the time in a setting with the delegating physician, she/he may also prescribe in the following settings:

       1. (i) a site in which health care services are provided for established patients only;
       2. (ii) a clinic run or sponsored by a nonprofit organization that provides voluntary charity health care services where the advanced practice registered nurse is not remunerated; or
       3. (iii) a setting where voluntary health care services are provided during a declared emergency or disaster at a temporary facility operated or sponsored by a governmental entity or nonprofit organization and established to serve persons in this state where the advanced practice registered nurse is not remunerated.
15. (15) Population focus area--The section of the population with which the advanced practice registered nurse has been licensed to practice by the Board.
16. (16) Prescribing--Determining the dangerous drugs or controlled substances that shall be used by or administered to a patient exercised in compliance with state and federal law.
17. (17) Protocols or other written authorization--Written authorization to provide medical aspects of patient care that are agreed upon and signed by the advanced practice registered nurse and the physician, reviewed and signed at least annually, and maintained in the practice setting of the advanced practice registered nurse. Protocols or other written authorization shall be defined to promote the exercise of professional judgment by the advanced practice registered nurse commensurate with his/her education and experience. Such protocols or other written authorization need not describe the exact steps that the advanced practice registered nurse must take with respect to each specific condition, disease, or symptom and may state types or categories of drugs that may be prescribed rather than just list specific drugs.
18. (18) Shall and must--Mandatory requirements.
19. (19) Should--A recommendation.
20. (20) Signing a prescription drug order--Completing a prescription drug order presigned by the delegating physician or the signing of a prescription by an advanced practice registered nurse. The advanced practice registered nurse must be designated to the Texas Medical Board by the delegating physician as a person delegated to sign a prescription.

21. (21) Site serving a medically underserved population--

    1. (A) a site located in a medically underserved area;
    2. (B) a site located in a health manpower shortage area;
    3. (C) a clinic designated as a rural health clinic under 42 USC 1395x(aa);
    4. (D) a public health clinic or a family planning clinic under contract with the Texas Health and Human Services Commission or the Texas Department of State Health Services;
    5. (E) a site located in an area in which the Texas Department of State Health Services determines there is an insufficient number of physicians providing services to eligible clients of federal, state, or locally funded health care programs; or
    6. (F) a site that the Texas Department of State Health Services determines serves a disproportionate number of clients eligible to participate in federal, state, or locally funded health care programs.

Source Note:The provisions of this §222.1 adopted to be effective November 26, 2003, 28 TexReg 10502; amended to be effective February 14, 2010, 35 TexReg 866.