Prescribing narcotics in the va system

TicAL · Apr 18, 2011

Hmm, from everything I've ever heard NPs are mid level providers. Anyways, I don't mean to be rude but this kind of sounds like an ego issue. If a doctors signature is needed then fine, get it so that your patients can be cared for. Work within the system and try not to feel bad...you're helping your patients.

Trauma Columnist · Apr 18, 2011

Could it be a state issue?

Mid-level provider is a common teem and I've never heard it used as a put down?

Dr. Tammy, FNP/GNP-C · Apr 18, 2011

I work in a outpatient clinic for the VA Administration in North Texas. Nurse Practitioners are not allowed to write any prescriptions for ANY controlled medications. Can anyone working for this sytem let me know what the restrictions are in your area. I retired from the army, and I find the VA in north texas not very receptive to "mid level providers". The DOD side of the house was more receptive and understanding toward my position than the VA system. Physicians call PAs and NPs mid-level providers. I had to inform them that I am a nurse practitioner and not a mid level provider. The process of looking for a physician to sign off on medications have caused me a lot anxiety, and patients longer wait times at the pharmacy. Please chime in.

You are correct in stating that you are not a mid level provider as a NP. Mid level provider status as a NP directly infers two critical elements: (1) As NP's, we are not in the profession of nursing but in the profession of medicine and (2) We as NP's cannot function outside of a supervisory relationship with a physician. Both of these are false as NP's are in the profession of nursing and NP's do indeed operate independent of a physician in 23 states.

Unfortunately, many--including some NP's on this site, are confused between that of an NP and that of a PA in that they lump themselves together as Mid Levels.

As to your present situation, you may want to point out another body of federal regulations to help inform your VA people that although lumping PA's together as NP's as mid levels is a common mistake, it is not appropriate. Specifically, use your Army regulations to help guide them.

AR 40-68 provides:

Page 27

7-4. Advanced practice registered nurse

c. Scope of practice.

(1) The APRN is a licensed and privileged practitioner and, as such, co-signature by a physician or other privileged

provider of APRN entries in the patient's medical record, prescriptions, and so forth, is not required.

Page 29

g. Nurse practitioner.

(3) Scope of practice.

(a) The NP practices independently and collaboratively with other health care professionals to provide primary care

and to diagnose, treat, and manage the patient's preventive, acute, and chronic health problems. Services include but

are not limited to ordering, conducting, and interpreting diagnostic and laboratory tests; prescribing pharmacologic

agents and nonpharmacologic therapies; and teaching and counseling individuals, Families, and groups.

7-16. Physician assistant and specialty physician assistant

a. Description. PAs are health care providers who deliver primary or specialty medical care with physician

supervision. Within that physician-PA relationship, PAs exercise significant professional autonomy in medical decision

making and provide a broad range of diagnostic and therapeutic services to all DOD beneficiaries.

(f) Authentication of medical record entries. PAs will sign all entries made in the patient's inpatient treatment record

(ITR) or outpatient treatment record (OTR). Documentation in the ITR of the patient's medical history, physical

examination, and narrative summary, as well as entries on DA Form 4256 (Doctor's Orders) (see AR 40-66) require

physician countersignature. Countersignature will be within 24 hours. Entries made by a PA in the HREC or the OTR

do not require a physician's countersignature.

sandnnw, BSN, MSN, EMT-B, APRN · Apr 19, 2011

Interesting how the VA works, eh?

In this case, it may have more to do with your state license. I write for narcotics almost every hour at the VA, no co-signer, no restrictions. I'm surprised by this, as the VA is a federal institution and you would think, one VA is all VA as far as policy. Perhaps its your clinic specifically? Find that difficult to believe, considering the amount of narcotics dispensed at VAs.

I have heard rumors of problems at some VA sites, including the Pain Clinics taking over Rx for narcotics. I'd look into it further. As for me, I'd love not to have to write them. So many times, my ethics meter jumps and the social issues behind these Rx just make my skin crawl.

I'm glad to see the rise of the Pain specialty.

CRF250Xpert · Apr 19, 2011

What meds are you looking for someone to sign off on? If you are in Texas, you can only Rx Sched III and above - if you are following our state laws. Maybe the VA ignores state law as mil installations tend to do. Personally, I prefer the hypovicodinemic patients to hear "I'm just a nurse - I can't Rx any narcs, sorry".

CRF250Xpert · Apr 19, 2011

So many times, my ethics meter jumps and the social issues behind these Rx just make my skin crawl.

Ditto. How come people never have any issues with metoprolol? That Rx never gets lost, eaten by the dog, friend stole it, never showed up, aunt's uncle's boyfriend's brother's mother misplaced the..., or whatever the lame excuse is DeJour. Maybe metoprolol isn't worth much on the street?

79Tango · Apr 19, 2011

It also could depend on the Credentials the facility has given you. Are you a GS employee or contractor? Once you have passed VetPro your credentials packet will typically be sent to a committee for signatures and final approval. Ive seen some providers given more independence than others.