Orthopedic FNP Texas

[littlebelle1293]

Hello all

I'm currently in the FNP program at Texas Tech, due to graduate in August and trying to figure out what to do afterwards. My background is ICU for 2 years and Ortho for the last 3 years. I always thought I would go to Family Practice when done with my FNP but, as I am nearing completion of my program, Ortho surgeons I work with are asking me about potentially joining their respective practices. While I love the idea of staying in Ortho, I am unsure of what my role, as an FNP, would be.

I realize seeing patients in clinic- injuries, pre-op, and post-op would be a big part of it so the surgeon could be in the OR where he makes his big $$$. But the surgeons I work with employ PAs and don't seem to think there is a difference between the two. I see PAs assist in the OR frequently, but as an FNP, the only way I could do that is with an RNFA, correct?

Also, they could not ask me to round or deal with anything inpatient, correct? I really wish Tech offered a course on this type of issue as I am months away from graduation and am unclear of my scope in this field. Anyone who has a clue about how this works in Texas, please advise.

Thanks

[littlebelle1293]

Thanks so much questions answered :)

[Jeremy G]

This is and interesting conversation. I've been working in the orthopedic nursing and first assisting role for 6+ years. Recently got my ANP certification. Before I did everything a PA would do in the hospital setting as an RN (rounding, admitting, consults, ED closed reductions, splinting, first assisting, suturing, you name it, accept seeing patients in the office). Remember your also a RN. All you need to do when writing orders is just like you did as a nurse. Just sign it as verbal order Dr. X and then your name and title. PA's do this too. If your ANP, FNP, GNP, just sign as a verbal order and the physician will co-sign or medical records will have him sign later. Also, for FNP and ANP in the clinic, same thing if unsure just have your MD cosign all your charts. This will allow higher billing and a better salary for you, plus liability protection. Nothing to worry about. I would encourage getting certified in all areas you work anyway. I do pretty much anything in surgery as long as the physician allows it and my licenses allow this. The only thing I don't do is make the initial incision. I assist and help the surgery, but I will not do the surgery for him or her. That's the difference. In surgical first assisting it's important understand that the surgeon is the "captain". i.e. if he ask you to drill something and while your drilling he say "stop", you STOP. Let him/her instruct you doing whatever he ask of you in the procedure. Don't ever assume command yourself. Always respect what he instructs and tells you. In this way the surgeon is the one who assumes the liability. We recently had a CST,CSFA make the initial incision before the surgeon entered the room and this became a huge deal and that person will lose privileges at that facility and the facility can and may report that person to the board. Just remember the surgeon leads the surgery period.

Jeremy G, MSN, ANP-BC, RN, ONC, CSFA, LSA

[core0]

This is and interesting conversation. I've been working in the orthopedic nursing and first assisting role for 6+ years. Recently got my ANP certification. Before I did everything a PA would do in the hospital setting as an RN (rounding, admitting, consults, ED closed reductions, splinting, first assisting, suturing, you name it, accept seeing patients in the office). Remember your also a RN. All you need to do when writing orders is just like you did as a nurse. Just sign it as verbal order Dr. X and then your name and title. PA's do this too. If your ANP, FNP, GNP, just sign as a verbal order and the physician will co-sign or medical records will have him sign later. Also, for FNP and ANP in the clinic, same thing if unsure just have your MD cosign all your charts. This will allow higher billing and a better salary for you, plus liability protection. Nothing to worry about. I would encourage getting certified in all areas you work anyway. I do pretty much anything in surgery as long as the physician allows it and my licenses allow this. The only thing I don't do is make the initial incision. I assist and help the surgery, but I will not do the surgery for him or her. That's the difference. In surgical first assisting it's important understand that the surgeon is the "captain". i.e. if he ask you to drill something and while your drilling he say "stop", you STOP. Let him/her instruct you doing whatever he ask of you in the procedure. Don't ever assume command yourself. Always respect what he instructs and tells you. In this way the surgeon is the one who assumes the liability. We recently had a CST,CSFA make the initial incision before the surgeon entered the room and this became a huge deal and that person will lose privileges at that facility and the facility can and may report that person to the board. Just remember the surgeon leads the surgery period.

Jeremy G, MSN, ANP-BC, RN, ONC, CSFA, LSA

I'm going to let the NPs comment on whether you are within your scope of practice as an RN rounding, admitting, consults, ED closed reductions etc. I can't imagine you are in any state or hospital I've worked in.

As for billing, for gods sake please take a billing class before you give advice. Having the physician co sign the chart does not allow you to bill at a higher level. I won't comment on the rest but it sounds as out of bounds as writing consults as an RN.

[aprnKate]

I was told in my FNP program specifically that that we are not allowed to first assist unless we have a RNFA certificate. Back then there are FNPs who can work in acute care settings and there still some that do like in the ED fast track. However, they are trying to make a distinction between ACNP and FNPs. I would not even risk doing procedures like that. Only minor procedures in the office like abscess drainage or joint injections/aspirations are fine.

[legume]

It is my understanding that the Texas BON is intentionally vague in their delineation of scope of practice as it relates to ACNP versus FNP. Many hospitals are now setting hard boundaries, but that is up to the institution. One could argue that an RN with 3 years of inpatient ortho experience is well under way to care for ortho patients in an acute care clinic setting as an FNP. As long as you are properly trained to perform the tasks to which you are delegated, you should be operating within your personal scope of practice.

[ghillbert, MSN, NP]

The following were taken from the 2008 Consensus APRN model.

The link is provided on the Texas BON website.

"Scope of practice of theprimary care or acute care CNP is

not setting specific but is based on patient care needs. Programs may

prepare individuals across both the primary care and acute care CNP competencies."

The point is that FNPs are trained and educated in PRIMARY CARE, not in acute care. You're right, the setting of clinic v hospital is not the important factor in the consensus model. The important factor is that hospital patients undergoing surgery are not primary care patients; they are clearly and obviously acute care patients.

JeremyG - in your scenario, what's the point of becoming a CRNP if you "verbal order" everything and bill under the physician's NPI?