Untitled California Attorney General Opinion ( 1988 )

TO BE PUBLISHED IN THE OFFICIAL REPORTS
OFFICE OF THE ATTORNEY GENERAL
State of California
JOHN K. VAN DE KAMP
Attorney General
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:
OPINION : No. 88-303
:
of : November 3, 1988
:
JOHN K. VAN DE KAMP :
Attorney General :
:
JACK R. WINKLER :
Assistant Attorney General :
:
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THE PHYSICIAN'S ASSISTANT EXAMINING COMMITTEE OF THE
BOARD OF MEDICAL QUALITY ASSURANCE has requested an opinion on the
following questions:
1. May a physician assistant lawfully initiate, on
behalf of his or her supervising physician orders for:
(a) routine laboratory tests,
(b) routine diagnostic radiological services,
(c) therapeutic diets,
(d) physical therapy treatments,
(e) occupational therapy treatments, or
(f) respiratory care services
for the diagnosis or treatment of a patient of the supervising
physician?
2. May a physician assistant lawfully transmit the
orders of his or her supervising physician for the six services
specified in the first question?
3. May a physician assistant lawfully initiate or
transmit the order of his or her supervising physician for life
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saving emergency treatment for a patient of the supervising
physician?
4. May a physician assistant lawfully initiate or
transmit the order of his or her supervising physician for routine
nursing services for a patient of the supervising physician?
5. May a physician assistant lawfully initiate or
transmit the orders of his or her supervising physician referred to
in the first four questions without a protocol?
6. Must the orders referred to in the first four
questions be countersigned by a supervising physician before they
may be carried out?
7. When the law conditions the actions of a licensed
health care professional upon an order of a physician will an order
for such action initiated or transmitted by a physician authorize
such licensee to perform the action so ordered?
8. Are the medical services a physician assistant is
authorized to perform by the regulation governing a physician
assistant's authority for the administration of medication to a
patient limited to a specific practice site, facility or
institutional setting?
CONCLUSIONS
1. A physician assistant may not lawfully initiate, on
behalf of his or her supervising physician, orders for:
(a) routine laboratory tests,
(b) routine diagnostic radiological services,
(c) therapeutic diets,
(d) physical therapy treatments,
(e) occupational therapy treatments, or
(f) respiratory care services
for the diagnosis or treatment of a patient of the supervising
physician.
2. A physician assistant may lawfully transmit the
orders of his or her supervising physician for the six services
specified in the first conclusion in the institutional setting but
not elsewhere.
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3. A physician assistant may initiate personally and
directly treatment procedures essential for the life of a patient.
Where the emergency care is beyond the physician assistant's scope
of practice a physician assistant may not lawfully initiate or
transmit the order of his or her supervising physician to others
for lifesaving emergency treatment for a patient of the supervising
physician but may transmit and in some cases implement transport
back-up procedures for the immediate care of patients pursuant to
written procedures established by the physician assistant and the
supervising physician.
4. A physician assistant may lawfully transmit the order
of his or her supervising physician to a nurse to administer
medications and therapeutic agents to implement a treatment of the
supervising physician's patient but may not initiate such an order.
A physician assistant may also order the drawing of blood from a
patient of his or her supervising physician to provide a sample for
a routine laboratory test when such test has been authorized by the
supervising physician. To the extent that a physician may properly
give orders to other licensed health care professionals regarding
other routine nursing services for the physician's patient his or
her physician assistant may lawfully transmit such orders to
others. We find no other authority for a physician assistant to
order routine nursing services.
5. The orders referred to in the first four conclusions
which a physician assistant may lawfully initiate or transmit may
be issued without a protocol when the supervising physician has not
included protocols as one of the authorized mechanisms for
supervision in the written guidelines for supervision of the
physician assistant.
6. The orders referred to in the first four conclusions
which may be lawfully initiated or transmitted by a physician
assistant need not be countersigned by a supervising physician
before they are carried out unless this supervising mechanism is
included in the written guidelines for the supervision of the
physician assistant.
7. When a statute conditions the actions of a licensed
health care professional upon an order of a physician an order of
a physician transmitted by a physician assistant but not an order
initiated by a physician assistant will authorize the licensed
recipient to carry out the order.
8. The medical services a physician assistant is
authorized to perform by the regulation governing a physician
assistant's authority for the administration of medication to a
patient are not limited to a specific practice site, facility or
institutional setting unless such limitation is imposed by the
supervising physician.
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ANALYSIS
Background
A new category of health care professional called the
"physician assistant"1 was created in 1970 by the enactment of the
Physician's Assistant Practice Act (the "Act") as section 3500 et
seq. of the Business and Professions Code. The purposes of the Act
are stated in section 3500 as follows:
"In its concern with the growing shortage and
geographic maldistribution of health care services in
California, the Legislature intends to establish in this
chapter a framework for development of a new category of
health manpower -- the physician's assistant.
"The purpose of this chapter is to encourage the
more effective utilization of the skills of physicians by
enabling them to delegate health care tasks to qualified
physicians' assistants where such delegation is
consistent with the patient's health and welfare.
"This chapter is established to encourage the
utilization of physician's assistants by physicians, and
to provide that existing legal constraints should not be
an unnecessary hindrance to the more effective provision
of health care services. It is also the purpose of this
chapter to allow for innovative development of programs
for the education of physician's assistants."
The Act provides for the licensing of physician
assistants following examination to establish that applicants meet
education and training requirements. The Act does not undertake to
define the scope of practice of the physician assistant. Instead
Section 3502 of the Act provides that "a physician assistant may
perform those medical services as set forth by the regulations of
the board [the Division of Allied Health Professions of the Board
of Medical Quality Assurance referred to as the "board" in this
opinion] when such services are rendered under the supervision of
a licensed physician or physicians approved by the board." We must
therefore look to those regulations to determine what medical
services a physician's assistant may perform.
The Physician Assistants Regulations ("regulations"
herein) are found in chapter 13.8 of title 16 of the California
Code of Regulations in section 1399.500 through section 1399.556.
To simplify our references to these regulations we will omit use of
1
While the Act refers to the new category as a "physician's
assistant" the regulations use the term "physician assistant",
dropping the 's. We use the latter terminology.
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"section 1399" which precedes the decimal in all of these
regulations and refer to them simply as regulation 5-- using that
part of section number following the decimal. Thus regulation 500
refers to section 1399.500 in title 16 of the California Code of
Regulations. Regulations 530 through 539 specify the education and
training requirements for physician assistants. Regulations 540
through 545 define the scope of practice of the physician assistant
and are set forth in full in the Analysis and Appendix to this
opinion.
The questions presented require us to interpret these
regulations. In approaching that task we note first that the
Legislature has deferred to the expertise of the medical profession
to define what medical services the physician assistant may perform
by authorizing the board to adopt regulations specifying such
services.2 We will also defer to the expertise of the medical
profession by interpreting the regulations to authorize only those
services which are stated in clear unambiguous language and we will
not undertake to add to those services by implications or broad
interpretation of ambiguous words. Should our interpretation be
narrower than that intended by the board it may be corrected by the
relatively simple process of amending the regulations to clearly
spell out the board's intention. We believe this preferable to a
broader interpretation which the board may not have intended which
could jeopardize the health and lives of patients.
General Qualifications
Before considering specific medical services it should be
noted that the authority of a physician assistant to perform any
medical service is qualified by section 3502 in the Act to those
services which "are rendered under the supervision of a licensed
physician or physicians approved by the board." This means that a
physician assistant may not lawfully perform any medical service
which constitutes the practice of medicine without supervision and
that supervision may be provided only by those physicians who have
been approved by the board.
Regulation 540 creates three additional general
qualifications which a physician assistant must meet before he or
she is authorized to perform any medical service, namely:
(1) He or she must be competent to perform the medical
service in question;
2
For purposes of this opinion we assume that the statutory
authority to adopt regulations granted to the board meets
constitutional requirements. For a discussion of that matter see
Comment, the Physicians' Assistant in California -- A Better Legal
Foundation, 12 Santa Clara Lawyer 107, 11-113 (1972).
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(2) He or she may provide only those medical services
which are consistent with his or her education, training and
experience; and
(3) He or she must be authorized in writing to provide
the medical service in question by a supervising physician who is
responsible for the patients cared for by that physician's
assistant.
Section 545 creates two more general qualifications,
namely:
"(a) A supervising physician shall be available in
person or by electronic communication when the physician assistant
is caring for patients.
"(b) A supervising physician shall delegate to a
physician assistant only those tasks and procedures consistent with
the supervising physician's specialty or usual and customary
practice and with the patient's health and condition."
Since all the questions presented address specific
medical service we are not called upon to interpret these general
qualifications. It is assumed for purposes of this opinion that in
discussing the authority of a physician assistant to perform a
specific medical service that he or she possesses all of the
general qualifications required by the Act and the regulations.
Initiating Orders
We are asked in the first question whether a physician
assistant may lawfully initiate,3 on behalf of his or her
supervising physician, an order4 for six specified health care
services. It is apparent that this question has reference to the
medical services which a physician assistant is authorized to
3
We assume the word "initiate" as used in the questions refers
to the physician assistant originating the order without the
authority of a supervising physician which both identifies the
patient and specifies the particular services to be rendered.
4
Webster defines "order" as a command, direction or
instruction, usually backed by authority. When used in this sense
an order connotes an authorization to do the act ordered and
implies a duty on the recipient of the order to comply. The duty
of one licensed health professional to comply with the orders of
another depend upon contractual arrangements which are not
mentioned in the opinion request. We therefore understand the word
"order" as used in the questions to refer only to the physician
assistant's authority to authorize the act ordered and not to the
duty, if any, of the recipient to comply.
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perform by section 541(f). That section provides that a physician
assistant may:
"(f) Assist the physician in the institutional
setting (including general acute care hospitals, acute
psychiatric hospitals, skilled nursing facilities,
intermediate care facilities, and special hospitals as
defined in Section 1250 of the Health and Safety Code) by
arranging admissions, by taking complete histories and
performing physical examinations, by completing forms and
charts pertinent to the patient's medical record, by
providing services to patients requiring continuing care,
including patients at home. This assistance also
includes the review of treatment and therapy plans, the
ordering of routine diagnostic laboratory tests and
procedures and routine diagnostic radiological services,
such as bone and chest x-rays, the ordering of
therapeutic diets, physical therapy treatments,
occupational therapy treatments and respiratory care
services, and by evaluating patients and performing the
procedures and tasks specified in subsections (a), (b),
and (c) above and acting as first or second assistant in
surgery under the supervision of an approved supervising
physician. Nothing in this section shall be construed as
authorizing a physician's assistant to prescribe
medication, unless he or she is engaged in a health
manpower pilot project pursuant to Section 3502.1 of the
code." (Emphasis added.)
The six medical services referred to in the first question are
mentioned in regulation 541(f) and in the same order. Those six
medical services are among those listed as included in "this
assistance" referring to the first sentence stating in part:
"Assist the physician in the institutional setting . . .." Does
this language authorize a physician assistant to initiate an order
for one of the six listed services?
First we consider the significance of the words "assist
the physician" as used in regulation 541(f). We understand the
words to mean that the physician assistant may order the specified
services only when they will "assist" the physician. What does
"assist" mean in this context? First, we think the word signifies
that the role of physician's assistant is secondary to that of the
physician. It is the training, skill and judgment of the physician
that the patient relies on to diagnose and treat his or her
illness. While regulation 541(f) allows a supervising physician to
delegate some tasks to a physician's assistant to assist the
physician to make the diagnosis and determine the treatment those
tasks must be limited to assistance to the physician's role, not a
replacement of it. The services which regulation 541(f) authorizes
a physician assistant to order include physical therapy treatments
and occupational treatments. If this authorized the physician
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assistant to initiate the order for such treatments it would be the
physician assistant, not the physician, who determines the
treatment of the patient. This would replace, not "assist" the
physician in determining the treatment for the patient. By
limiting the ordering functions in regulation 541(f) to those which
"assist the physician" we believe the board intended to limit the
physician assistant to those orders which have been previously
authorized by the physician. We therefore construe regulation
541(f) to authorize a physician's assistant to transmit a
supervising physician's order for the listed services to others but
not to initiate such orders.
We conclude that a physician assistant may not lawfully
initiate, on behalf of his or her supervising physician, orders for
the six services specified in the first question for the diagnosis
or treatment of a patient of the supervising physician.
Transmitting Orders
The second questions asks whether a physician assistant
may lawfully "transmit"5 the orders of his or her supervising
physician for the six services specified in the first question. In
our analysis of the first question we interpreted regulation 541(f)
to authorize a physician assistant to transmit a supervising
physician's order for the services listed but not to initiate such
orders. However, the authority to transmit such orders is
qualified by the words "in the institutional setting." This means
that the services a physician assistant is authorized to provide by
regulation 541(f) may only be provided in general acute care
hospitals, acute psychiatric hospitals, skilled nursing facilities,
intermediate care facilities, special hospitals as defined in
6
Health and Safety Code section 1250 and in like institutions.
The reference to providing services "to patients requiring
continuing care, including patients at home" in the first sentence
of regulation 541(f) authorizes continuation of such assistance to
patients after they leave the institutional setting. However, it
does not authorize such assistance to patients who were not in such
5
We understand the word "transmit" as used in the questions to
refer to relaying an order originating with a supervising physician
by a physician assistant to another to be performed by the other
person.
6
We construe the word "including" in the parenthetical list of
institutions in regulation 541(f) to be a word of enlargement
rather than one of limitation. We then apply the rule of
construction known as ejusdem generis to conclude that the
"institutional setting" referred to in regulation 541(f) means only
those institutions listed and those which are similar to those
listed. See 67 Ops.Cal.Atty.Gen. 122, 136-137 for a discussion of
these rules of construction.
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institution or for any such assistance that is not related to the
condition for which they were in the institution.
We conclude that a physician assistant may lawfully
transmit the orders of his or her supervising physician for the six
services specified in the first question in the institutional
setting but not elsewhere.
Lifesaving Emergency Treatment
The third question asks whether a physician assistant may
lawfully initiate or transmit orders for "lifesaving emergency
treatment." In the list of orders authorized by regulation 541(f)
lifesaving emergency treatment is not mentioned. However, the
regulations address emergency situations in two other regulations.
Regulation 541 provides that a physician assistant may:
"(d) Recognize and evaluate situations which call for
immediate attention of the physician and institute, when
necessary, treatment procedures essential for the life of
the patient."
Regulation 545(d) provides:
"The physician assistant and the supervising
physician shall establish in writing transport and back­
up procedures for the immediate care of patients who are
in need of emergency care beyond the physician
assistant's scope of practice for such times when a
supervising physician is not on the premises."
Except for transport of the patient we see nothing in either of
these regulations which authorizes a physician's assistant to
initiate or transmit orders to others to act in emergencies. The
first authorizes the physician assistant to "institute treatment
procedures" when necessary and essential for the life of the
patient but also contemplates that the physician will be called
immediately. We think this is limited to actions which the
physician assistant does directly and personally. The second
provides the procedures to be followed when the emergency occurs
when the supervising physician is not on the premises. These call
for transport of the patient to other facilities and back up by
other available physicians. They do not contemplate a physician
assistant directing the treatment actions of others in emergency
situations. The written procedures might well include
authorization to the physician assistant to make arrangements for
the transportation of the patient, by ambulance or otherwise, to
other facilities. However, the written procedures may not
authorize a physician assistant to give orders to others regarding
the diagnosis or treatment of the patient.
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We conclude that a physician assistant may initiate
personally and directly treatment procedures essential for the life
of a patient. We also conclude that where the emergency care is
beyond the physician assistant's scope of practice a physician
assistant may not lawfully initiate or transmit the order of his or
her supervising physician to others for lifesaving emergency
treatment for a patient of the supervising physician but may
transmit and in some cases implement transport back-up procedures
for the immediate care of patients pursuant to written procedures
established by the physician assistant and the supervising
physician.
Routine Nursing Services
The fourth question asks whether the physician assistant
may initiate or transmit orders of his or her supervising physician
for "routine nursing services". We note that nothing in regulation
541(f) mentions the ordering of routine nursing services by a
physician assistant. We must first determine what the question
means by "routine nursing services." Business and Professions Code
section 2725 in the Nursing Practices Act (the NPA) provides in
part:
"The practice of nursing within the meaning of this
chapter means those functions, including basic health
care, which help people cope with difficulties in daily
living which are associated with their actual or
potential health or illness problems or the treatment
thereof which require a substantial amount of scientific
knowledge or technical skill, and includes all of the
following:
"(a) Direct and indirect patient care services that
insure the safety, comfort, personal hygiene, and
protection of patients; and the performance of disease
prevention and restorative measures.
"(b) Direct and indirect patient care services,
including, but not limited to, the administration of
medications and therapeutic agents, necessary to
implement a treatment, disease prevention, or
rehabilitative regimen ordered by and within the scope of
licensure of a physician, dentist, podiatrist, or
clinical psychologist, as defined by Section 1316.5 of
the Health and Safety Code.
"(c) The performance of skin tests, immunization
techniques, and the withdrawal of human blood from veins
and arteries.
"(d) Observation of signs and symptoms of illness,
reactions to treatment, general behavior, or general
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physical condition, and (1) determination of whether such
signs, symptoms, reactions, behavior, or general
appearance exhibit abnormal characteristics; and (2)
implementation, based on observed abnormalities, of
appropriate reporting, or referral, or standardized
procedures, or changes in treatment regimen in accordance
with standardized procedures, or the initiation of
emergency procedures."
Which of these services a registered nurse is authorized to perform
are "routine" within the meaning of question 4?
The services described in (a) might be described as
"routine nursing services." However in 67 Ops.Cal.Atty.Gen. 122,
139 we observed that subdivision (a) was intended to describe "the
traditional, unique and nursing functions that do not depend on
physician direction." Since the question speaks in terms of a
physician's assistant giving "orders" for routine nursing services
it would not appear to embrace the services described in (a).
Registered nurses perform those services on their own authority
without orders from other health care professionals.
Similarly, the functions authorized by subdivision (d) are
undertaken by registered nurses on their own initiative and do not
contemplate orders from other health professionals. Thus they do
not appear to be routine nursing services within the meaning of
question 4.
The administration of medications and therapeutic agents
by registered nurses authorized in (b) is conditioned upon an order
from a physician, dentist, podiatrist or clinical psychologist. We
assume these are included in the "routine nursing services"
contemplated in the question in the light of regulation 541 which
provides in part that a physician assistant may:
"(h) Administer medication to a patient, or transmit
orally, or in writing on a patient's record, a
prescription from his or her supervising physician to a
person who may lawfully furnish such medication or
medical device. The supervising physician's
prescription, transmitted by the physician assistant, for
any patient cared for by the physician assistant, shall
be based either on a patient-specific order by the
supervising physician or on written protocol which
specified all criteria for the use of a specific drug or
device and any contraindications for the selection. A
physician assistant shall not provide a drug or transmit
a prescription for a drug other than that drug specified
in the protocol, without a patient-specific order from a
supervising physician. At the direction and under the
supervision of a physician supervisor, a physician
assistant may hand to a patient of the supervising
physician a properly labeled prescription drug
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prepackaged by a physician, a manufacturer, as defined in
the Pharmacy Law, or a pharmacist. In any case, the
medical record of any patient cared for by the physician
assistant for whom the physician's prescription has been
transmitted or carried out shall be reviewed and
countersigned and dated by a supervising physician within
seven (7) days. A physician assistant may not
administer, provide or transmit a prescription for
controlled substances in Schedules II through V inclusive
without patient-specific authority by a supervising
physician."
While this regulation contemplates a physician's assistant
transmitting a physician's prescription to others it may only be
transmitted to "a person who may lawfully furnish such medication."
This would include a registered nurse where the physician's
assistant is transmitting the physician's patient specific order.
In such case the nurse has authority to administer the medication
because it was ordered for the patient by a physician. However, as
we more fully discuss in the analysis of question 7, when the
physician assistant's order is based upon a protocol for use of the
drug which is not patient specific we cannot say that its use has
been "ordered by a physician" as those words are used in Business
and Professions Code section 2725(b) to authorize a registered
nurse to administer the drug.
The authority of a registered nurse in Business and
Professions Code section 2725(c) to perform skin tests,
immunization techniques, and the withdrawal of human blood from
veins and arteries is not conditioned upon an order from a
physician or other licensed practitioner. The "routine nursing
services" contemplated in the question may include such services.
The question asks in part whether a physician's assistant may
initiate or transmit a physician's order for such services. The
only regulation we have found which might give a physician
assistant the authority to order such services is regulation
541(f), and more specifically in that wording which authorizes "the
ordering of routine laboratory tests and procedures" when it
assists the physician. We have already noted that this is limited
to orders previously authorized by the physician. We believe the
words "and procedures" following "routine laboratory tests" in
regulation 541(f) means procedures which are necessary or ancillary
to the laboratory tests. This would include the drawing of blood
to obtain a sample for the performance of routine diagnostic
laboratory tests. Thus regulation 541(f) gives a physician
assistant authority to order the drawing of a blood sample to be
used for a routine laboratory test. Whether such an order
authorizes the recipient to comply is the subject of question 7.
We see no authority in regulation 541(f) or other regulations for
a physician assistant to order blood drawn for other purposes or to
order skin tests or immunizations.
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We conclude that a physician assistant may lawfully
transmit the order of his or her supervising physician to a nurse
to administer medications and therapeutic agents to implement a
treatment of the supervising physician's patient but may not
initiate such an order. A physician assistant may also order the
drawing of blood from a patient of his or her supervising physician
to provide a sample for a routine laboratory test when such test
has been authorized by the supervising physician. To the extent
that a physician may properly give orders to other licensed health
care professionals regarding other routine nursing services for the
physician's patient his or her physician assistant may lawfully
transmit such orders to others. We find no other authority for a
physician assistant to order routine nursing services.
Protocols
In question 5 we are asked whether a physician assistant
may lawfully initiate or transmit orders of his or her supervising
physician for the services referred to in the first four questions
without a protocol. Regulation 545(e) provides:
"(e) A physician assistant and his or her
supervising physician shall establish in writing
guidelines for the adequate supervision of the physician
assistant which shall include one or more of the
following mechanisms:
"(1) Examination of the patient by a supervising
physician the same day as care is given by the physician
assistant.
"(2) Countersignature and dating of all medical
records written by the physician assistant within thirty
(30) days that the care was given by the physician
assistant.
"(3) The supervising physician may adopt protocols
to govern the performance of a physician assistant for
some or all tasks. The minimum content for a protocol as
referred to in this section shall include the presence or
absence of symptoms, signs, and other data necessary to
establish a diagnosis or assessment, any appropriate
tests or studies to order, drugs to recommend to the
patient, and education to be given the patient. For
protocols governing procedures, the protocol shall state
the information to be given the patient, the nature of
the consent to be obtained from the patient, the
preparation and technique of the procedure, and the
follow-up care. Protocols shall be developed by the
physician or adopted from texts or other sources.
Protocols shall be signed and dated by the supervising
physician and the physician assistant. The supervising
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physician shall review, countersign, and date a minimum
of 10% sample of medical records of patients treated by
the physician assistant functioning under these protocols
within thirty (30) days. The physician shall select for
review those cases which by diagnosis, problem, treatment
or procedure represent, in his or her judgment, the most
significant risk to the patient;
"(4) Other mechanisms approved in advance by the
committee."
This regulation requires that a supervising physician
establish written guidelines for the supervision of a physician
assistant. Protocols are one of the four authorized mechanisms for
the supervision of a physician assistant. However, the written
guidelines need establish only "one or more" of the authorized
mechanisms of supervision. It follows that if one of the other
authorized mechanisms of supervision are established by the written
guidelines the use of protocols is not required.
We conclude that the orders referred to in the first four
questions which a physician assistant may lawfully initiate or
transmit may be issued without a protocol when the supervising
physician has not included protocols as one of the authorized
mechanisms for supervision in the written guidelines for
supervision of the physician assistant.
Countersignatures
In our analysis of the previous question we quoted
regulation 545(e) which requires written guidelines for the
supervision of a physician assistant which must include one or more
of four listed mechanisms. One of the listed supervision
mechanisms was "[c]ountersignature and dating [by a supervising
physician] of all medical records written by the physician
assistant within thirty (30) days that the care was given by the
physician assistant." As we noted in the case of protocols,
countersignatures are only one of four authorized mechanisms
of supervision. The supervising physician may employ one or more
of the other authorized supervision mechanisms without including
the countersignature mechanism.
Regulation 545(e) is not the only regulation referring to
countersignatures, however. Regulation 541(h) quoted above also
provides that a supervising physician shall review and countersign
prescriptions which have been transmitted or carried out by the
physician assistant. Regulation 541(h) requires the
countersignature of a supervising physician when an order
prescribing medications is transmitted by a physician assistant
whether the order is based on patient-specific order of a
supervising physician or a protocol for use of the particular drug.
However the countersignature is not required before the medication
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is administered, though it must be provided within seven days
thereafter.
We conclude that the orders referred to in the first four
questions which may be lawfully initiated or transmitted by a
physician assistant need not be countersigned by a supervising
physician before they are carried out unless this supervising
mechanism is included in the written guidelines for the supervision
of the physician assistant.
Authority of Recipient of Order
When a statute conditions the actions of a licensed
health care professional upon an order of a physician will an order
for such action initiated or transmitted by a physician assistant
authorize such licensee to carry out the order?
The focus of the previous questions has been upon the
authority of a physician assistant to give certain orders. While
the law may authorize a physician assistant to give an order it
does not follow that the recipient of the order may lawfully carry
it out. Question 7 requires us to examine the legal authority of
a recipient to carry out an order from a physician assistant.
Since the recipient of the order is a licensed health care
professional we must look to the law governing the practice of the
recipient to determine that authority.
The question further limits our inquiry to those actions
for which the law governing the practice of the recipient requires
an order from a physician or other specified licensed health care
professional to authorize the recipient to perform the action. We
are asked whether an order initiated or transmitted by a physician
assistant will suffice as the order of a physician within the
meaning of the law governing the practice of the recipient and thus
authorize the recipient to carry out such order.
When the order in question originates with a physician
and such order is transmitted by a physician assistant to another
licensed health care professional it is clear that the order is
that of the physician not the order of the physician assistant.
Such an order satisfies the requirement in the law governing the
practice of the recipient that the action be ordered by a physician
even though the order is transmitted to the recipient by a
physician assistant. It follows that the recipient is authorized
to carry out such an order.
However, when the order in question is initiated by a
physician assistant the requirement in the law governing the
recipient's practice that the action be ordered by a physician is
not satisfied. The fact that in initiating the order the physician
assistant is acting pursuant to a protocol or other general
authority from a supervising physician which does not specify both
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the action to be ordered and the patient for whom it is ordered
does not make the order that of the supervising physician for the
purpose of the law governing the practice of the recipient of the
order. It follows that the recipient is not authorized to carry
out such an order.
By way of example we note that the NPA authorizes a
registered nurse to provide "direct and indirect patient care
services, including, but not limited to, the administration of
medications and therapeutic agents, necessary to implement a
treatment, disease prevention, or rehabilitative regimen ordered by
and within the scope of licensure of a physician, dentist,
podiatrist, or clinical psychologist." (Bus. & Prof. Code,
§ 2725(b).) An order to administer a medication to a patient
initiated by a physician assistant would not be order by one of the
health care professionals specified in the NPA. Thus a registered
nurse would not have legal authority to carry out the order
initiated by a physician assistant. On the other hand a registered
nurse would have legal authority to carry out an order to medicate
a patient which originated with the patient's physician and was
transmitted to the registered nurse by a physician assistant.
We conclude that when a statute conditions the actions of
a licensed health care professional upon an order of a physician an
order of a physician transmitted by a physician assistant but not
an order initiated by a physician assistant will authorize the
licensed recipient to carry out the order.
Practice Site
The last question asks whether the medical services a
physician assistant is authorized to perform by the regulation
governing a physician assistant's authority for the administration
of medication to a patient is limited to any specific practice
site, facility or institutional setting. The regulation in
question is regulation 541(h) which has been quoted above. Unlike
regulation 541(f) which limits the authority granted the physician
assistant to assist the physician as provided therein to "the
institutional setting" there is nothing in regulation 541(h) which
itself limits the authority which may be given the physician
assistant to an institutional setting or other site. Of course the
supervising physician may limit the places where the physician
assistant may perform the services mentioned in regulation 541(h)
in the written delegation of authority required by regulation 540
or in the protocols which govern the physician assistant's actions.
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We conclude that the medical services a physician
assistant is authorized to perform by the regulation governing a
physician assistant's authority for the administration of
medication to a patient are not limited to a specific practice
site, facility or institutional setting unless such limitation is
imposed by the supervising physician.
* * * * *
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APPENDIX
Article 4. Practice of Physician Assistants
Regulation 540. Limitation on Medical Services
"A physician assistant may only provide those
medical services which he or she is competent to perform
and which are consistent with the physician assistant's
education, training, and experience, and which are
delegated in writing by a supervising physician who is
responsible for the patients cared for by that physician
assistant. The committee or division or their
representative may require proof or demonstration of
competence from any physician assistant for any tasks,
procedures or management he or she is performing. A
physician assistant shall consult with a physician
regarding any task, procedure or diagnostic problem which
the physician assistant determines exceeds his or her
level of competence or shall refer such cases to a
physician."
Regulation 541. Medical Services Performable.
"A physician assistant may:
"(a) Take an appropriate history; perform an
appropriate physical examination and make and assessment
therefrom, and record and present pertinent data in a
manner meaningful to the physician.
"(b) Perform and/or assist in the performance of
laboratory and screening procedures delegated by the
supervising physician where the procedures to be
performed are consistent with the physician's specialty
or usual and customary practice, and with the patient's
health and condition.
"(c) Perform or assist in the performance of
therapeutic procedures delegated by the supervising
physician where the procedures to be performed are
consistent with the physician's specialty or usual and
customary practice, and with the patient's health and
condition.
"(d) [quoted in the Analysis at p. 9.]
"(e) Instruct and counsel patients regarding
matters pertaining to their physical and mental health,
such as diets, social habits, family planning, normal
growth and development, aging, and understanding of and
long term management of their disease.
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"(f) [quoted in the Analysis at p. 6.]
"(g) Facilitate the physician's referral of
patients to the appropriate health facilities, agencies,
and resources of the community."
"(h) [quoted in the Analysis at p. 11.]
Regulation 542 Delegated Procedures.
"The delegation of procedures to a physician
assistant under Section 1399.541, subsections (b) and (c)
shall not relieve the supervising physician of primary
continued responsibility for the welfare of the patient."
Regulation 543 Training to Perform Additional Medical
Services.
"A physician assistant may be trained to perform
medical services which exceed his or her areas of
competency in the following settings:
"(a) In the physical presence of an approved
supervising physician who is directly in attendance and
assisting the physician assistant in the performance of
the procedure;
"(b) In an approved program;
"(c) In a medical school approved by the Division
of Licensing under Section 1314;
"(d) In a residency or fellowship program approved
by the Division of Licensing under Section 1321;
"(e) In a facility or clinic operated by the
Federal government;
"(f) In a training program which leads to licensure
in a healing arts profession or is approved as Category
I continuing medical education or continuing nursing
education by the Board of Registered Nursing."
Regulation 545 Supervision Required
"(a) [quoted in the analysis at p. 6.]
"(b) [quoted in the analysis at p. 6.]
"(c) A supervising physician shall observe or
review evidence of the physician assistant's performance
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of all tasks and procedures to be delegated to the
physician assistant until assured of competency.
"(d) [quoted in the Analysis at p. 9.]
"(e) [quoted in the Analysis at p. 13.]
"(f) In the case of a physician assistant operating
under interim approval, the supervising physician shall
review, sign and date the medical record of all patients
cared for by that physician assistant within seven (7)
days if the physician was on the premises when the
physician assistant diagnosed or treated the patient. If
the physician was not on the premises at that time, he or
she shall review, sign and date such medical records
within 48 hours of the time the medical services were
provided.
"(g) Except in a life-threatening situation, a
physician assistant shall perform surgery requiring other
than a local anesthesia only under the direct and
immediate supervision of an approved physician.
"(h) The supervising physician has continuing
responsibility to follow the progress of the patient and
to make sure that the physician assistant does not
function autonomously. The supervising physician shall
be responsible for all medical services provided by a
physician assistant under his or her supervision."
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