Covering physicians

anh06005, MSN, APRN, NP · Dec 21, 2015

I won't refill any meds for a patient who hasn't been seen for a year or more. Thankfully my MD's don't do much in terms of chronic controlled substances. If I don't feel comfortable refilling it I say they need to wait until the doctor returns.

If it's for a non controlled and patient has been seen recently I will go ahead and authorize the refill after I glance through the note and labs to make sure it's appropriate. In my state, though, we must have collaborative physician contracts. I still see patients independently pretty much. They review a few notes each month and have to be available for consultation if needed. Otherwise they don't have much to do with my practice.

Psychcns · Dec 21, 2015

I bet if you look at your nurse practice act it says that you have to assess a patient before you can prescribe for them. You may want to email your board anonymously (create a new email account). You may want to call your malpractice carrier. The most I would do is prescribe a few pills to hold them over to their next appointment with the MD if they are someone who comes in regularly. Even if you don't have a collaborating agreement with the MD you are seeing his/her patients and the two of you have to agree on how it is to be handled. Prescribing opiates without some of the safe guards you note is bad practice whether it is a NP PA or MD. I don't think you want any part of it. You have to educate your managers. You might need to offer to see some of these patients and do some education, set up pain contracts etc.

cayenne06, MSN, CNM · Dec 21, 2015

I am the only full time clinician at my clinic, so I refill prescriptions that were written by the two part time clinicians I work with- but only when appropriate. PA or NP, I would not be comfortable with the set up you are describing. And I think you are right; since you are not under anyone elses' license, you might be open to way more liability than a PA.

PG2018 · Dec 21, 2015

Don't refill anything you don't want to. I think pain (and suicide) contracts are a bit ridiculous, but some people really dig them. Personally, I think you've landed in a really bad position. Physician doesn't mean "best clinical judgment" so use your own. I hate managing meds for other people's patients. I get people from primary care all the time who say "My PCP doesn't want to treat my ________ so he wants you to handle it and prescribe ___________." What's more outlandish is when I get disabled people from group homes and assisted living who show up with "staff" and messages from the home's nurse(s) that say "increase X" or "add Y for Z." But back to my thesis, don't fill what you don't want to fill. Then search for a new job. I hope you're well compensated.

RiskManager · Dec 21, 2015

As a risk manager in your area, I have a couple of comments;

1. You should only refill or prescribe in accordance with your clinical judgment. If you think it is inappropriate to refill schedule drugs because lack of clinical indication or documentation, then you should not do so.

2. Your license may allow you to practice independently, but since you are employed by a healthcare facility, that facility has the right and obligation to require you to do things as their employee. Ideally, they are not asking you to do anything that you think is contraindicated by ethics or the law and you must point it out if that is happening. But arguing that you don't have to do something because you can practice independently is generally not a good idea. The facility has the absolute right to require you as an employee to colloborate with, consult with, or be supervised by a physician, for example, even if you are licensed as an independent provider. Bearing in mind the comments above about not doing anything you think is unethical or unlawful.

3. I have worked with a number of NPs who had an independent practice for years, and it was a shock to them when they got bought out by Providence, or Peace Health, or Legacy, or somebody and became an employee. There is definitely the potential of losing your autonomy to a degree. In my experience, most of them think that the new steady paycheck is a good trade.

cayenne06, MSN, CNM · Dec 22, 2015

2. Your license may allow you to practice independently, but since you are employed by a healthcare facility, that facility has the right and obligation to require you to do things as their employee. Ideally, they are not asking you to do anything that you think is contraindicated by ethics or the law and you must point it out if that is happening. But arguing that you don't have to do something because you can practice independently is generally not a good idea. The facility has the absolute right to require you as an employee to colloborate with, consult with, or be supervised by a physician, for example, even if you are licensed as an independent provider. Bearing in mind the comments above about not doing anything you think is unethical or unlawful.
3. I have worked with a number of NPs who had an independent practice for years, and it was a shock to them when they got bought out by Providence, or Peace Health, or Legacy, or somebody and became an employee. There is definitely the potential of losing your autonomy to a degree. In my experience, most of them think that the new steady paycheck is a good trade.

I think her point was not that she shouldn't "have" to do something because she has an independent license. Sounds to me like what she was saying is that this situation is particularly troublesome to her because, unlike the PAs she works with, she is not "covered" by someone elses' license (of course PAs are also responsible for their own clinical judgment and cannot justify poor practice by saying "the MD told me to").

All clinicians who are not self employed, regardless of type of licensure, are bound by the policies/protocols of their facility. Hopefully we all know that lol.

begonia60 · Dec 22, 2015

Thank you for your comments. Yes Cayenne, You are correct. I don't have a problem cleaning bedpans, I'm a nurse after all : )