NGR 6172 MIDTERM STUDY GUIDE
Week 1
Chapter 1: “Prescriptive Authority and Role Implementation”
It is generally agreed that providing health care includes: assessing health status, promoting health lifestyles, identifying/diagnosing normal and abnormal conditions, providing referrals, selec...
ngr 6172 midterm study guide week 1 chapter 1 “prescriptive authority and role implementation” it is generally agreed that providing health care includes assessing health status
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NGR 6172 MIDTERM STUDY GUIDE
Week 1
Chapter 1: “Prescriptive Authority and Role Implementation”
It is generally agreed that providing health care includes: assessing health status, promoting
health lifestyles, identifying/diagnosing normal and abnormal conditions, providing referrals,
selecting appropriate measures, implementing treatment, and supervising on an ongoing basis
-prevention, diagnosis, prescription, and treatment
Physicians were the first health care practitioners to gain legislative recognition
-very broad scope of practice; exclusive right to practice; preeminent position in a hierarchy of
health occupations; monopoly in healthcare
The role of the physician changed dramatically and driven by new technology and medications,
physicians have been attracted into specialty, leaving primary care
-Medicare reimbursement has fueled the growth of tertiary care
-emergence of nonphysicians; delivered high-quality and cost-effective care
Physician Payment Review Commission recommended changes in Medicare and the shift
directly increased financial reimbursement to clinicians who were providing primary care and
thus increased more providers to primary care
-increased access of care
Physicians and dentists are the professionals who traditionally have been given right to
prescribe
-has been thoroughly documented by the pharmaceutical industry
-types of medications prescribed are more closely monitored
-less research has been conducted on the appropriateness of physician prescriptive practices,
although the literature suggests that some physicians may write prescribes for problems that
might well respond to nonpharmacologic therapy
New drugs go through a trial: awareness, interest, evaluation, and trial
It has been suggested that financial ties to drug companies may influence physicians’
prescribing practices
Guidelines forbid pharmaceutical companies from giving to prescribers nonpatient care-related
items exceeding $100
Problems in the Prescribing Practice of Physicians
-Writing up-to-date prescriptions because of physician failure to keep abreast of changes
-Pharmaceutical companies influence practice and providing drug samples
-lack of time has become major; decreased patient encounters, inadequate history taking,
failure to define problem, and an overreliance on drug therapy
-consumers pressure to prescribe medications; overuse of antibiotics
-illegibility of prescriptions; use of preprinter prescription pads, fax machines, and computer
forms have helped
-providers may fail to detect or anticipate drug interactions; herbal and OTC
Chapter 2: “History Review of Prescriptive Authority”
Research on the practices of nonphysician providers has demonstrated that they are qualified to
provide primary care
-some nonphysician providers have added diagnostic and assessment skills to their
pharmacology knowledge
,Obtaining prescriptive authority was one of the major benchmarks achieved by these new
provider groups as they developed their new roles
The NP role and the physician assistant (PA) role paralleled each other
-however, the PA role was defined under the guidance and advocacy of the medical
profession Role of the federal government: the act of limited prescribing, dispensing,
manufacturing, and distribution to those individuals registered with the DEA
-narcotics and other drugs such as depressants and stimulants by their abuse potential, with
differing levels of control assigned to each class
-the DEA will register individuals who may prescribe narcotics and other controlled
substances; registration, however, depends on state authority to prescribe
controlled substances; other nurses working in states granting authority can apply
for a DEA #
-the role of who may prescribe, dispense, or administer belongs to the state
Although the state may establish a list of minimum requirements that one must meet to be
licensed, meeting them does not guarantee the provider is competent
Two types of prescriptive authority are afforded to NPs: delegable authority and authority
legislated by statutes
-Delegable authority requires the nurse to perform under the direction of a physician
-legislated by the state boards of nursing: dependent (physician has ultimate authority) and
independent (allows NP to prescribe alone)
Certified Nurse Specialists
-Scope of practice: study and supervised clinical practice; serve as an expert in clinical practice,
an educator, a consultant, a researcher, and an administrator
-Status of prescriptive authority: who work in homes and the community; around 30 states
give authority
Certified Registered Nurse Anesthetist
-Scope of practice: qualified to make independent judgements concerning all aspects of
anesthesia care and recognized in all states; performing and documenting a preanesthetic
assessment and evaluation; documenting and implementing an anesthetics plan;
initiating technique; selecting, obtaining, and administering anesthetics; emergence
anesthetics
-status of prescriptive authority: the term prescription does not include dispensing for
immediate administration; typically, do not need prescriptive authority; 5 states currently have
independent prescriptive authority for CRNAs
Certified Nurse-Midwives
-scope of practice: primary health care services for women from adolescence to after
menopause
-statues of prescriptive authority: legislative authority in all 50 states
Nurse Practitioner
-scope of practice: provide a level of care commensurate with that of physicians, well
accepted by their patients, and cost-effective; patients have similar or better outcomes with
APRNs
-statues of prescriptive authority: NPs have steadily granted authority; 19 states granted pull
independent authority; 30 states allow NPs to prescribe controlled substances with physician
involvement
Issues Common to All Advanced Practice Nurse Prescribers
, -federal policy has established that only health care providers who are granted prescriptive
authority to prescribe controlled substances by the state can be registered by the DEA
-Definition and Registration of Mid-Level Practitioners: letter M precedes any DEA #
-inappropriate use of DEA #: required for samples, sometimes required for billing/tracking
Dispensing Privileges
-federal law addresses the labeling and packaging requirements that must be followed; does
not exclude specific prescribers from dispensing medication; all NPs can receive and/or dispense
pharmaceutical samples but is limited to specific site or circumstances
-question of whether a prescription written by an authorized prescriber can be filled by a
central distribution pharmacy located in another state other than the one the NP is in (no laws
address this issue)
-even if NPs could prescribe in state and other state, the pharmacy has the right to reject
the prescription
Research of Prescriptive Practices
-limitations on prescriptive practice can effectively restrict the public’s access to affordable
and comprehensive primary care delivered by diagnosing and prescribing nurses
-in 1981, California guided a study in effort to guide future legislative initiatives surrounding
prescriptive authority for NPs and other midlevel providers
-barriers to practice for nurses in prescribing role: regulatory irregularity among states;
increased antagonism from organized medical groups competing with APNs for patients;
growing number of NP graduates without prior nursing experience; inequity in data collection
on physician prescribing patterns among pharmaceutical companies; difficulty in obtaining
prescribing data from PDMA
Prescriptive Authority and the Physician’s Assistant
-PAs have some authority to prescribe
-Practice medicine under the guidance of a physician; medical diagnostic, therapeutic, and
preventative services
-roles may include providing health care services that complement physician services, such as
health promotion and disease prevention, and/or assuming educational, research, and/or
administrative duties
-prescriptive authority: state regulatory agencies now tend to recognize prescribing activities
of PAs within circumscribed boundaries; constraints of prescribing (physician co-signature,
limitations of types of drugs, schedule II agents)
Chapter 9: “Establishing the Therapeutic Relationship”
Patients may not take their medications as instructed: does not understand the seriousness of
the condition, does not understand the instructions, forgot verbal instructions, difficulty
taking the medication, angry or depressed, wants attention, no transportation
Establishing trusting relationships:
-patient and provider should establish a long-term relationship; compliance and adherence
-time: a scarce commodity these days
-attitude: who owns the problem? You or the patient?
-information: most important is the history
-communication: effective and two-way
, -positive feedback: be supportive
Failure of the Therapeutic
Relationship
-drug noncompliance may be seen as the inappropriate self-administration of medications
-problematic behavior can be exhibited as overutilization or underutilization of medication
-risk factors include: increases with preventative therapy, duration of therapy, greatest for
regimens that require significant behavioral change, poor understanding of instructions,
complex treatment regimen, unpleasant side effects, increases in drug costs
Chapter 10: “Practical Tips on Writing Prescriptions”
Drug Schedules
-drugs in schedule I have the highest potential for abuse, and their use is limited to research
protocols, instructional purposes, or chemical analysis
-schedule V drugs are available by prescription of OTC
-Schedule II, III, IV must contain a symbol that designates the schedule to which it belongs and
the following warning: “Caution”
-internet and mail-order pharmacies may not fill prescriptions for controlled substances
Components of the Traditional Prescription
-most states insist that the hospital name or the imprinted name of the prescriber, along with
credentials, address, and telephone number must be printed on the prescription pad for
controlled substances
-top portion: name and address of the patient, date that the prescription is written, age and
weight of the patient
-middle portion: superscription (Rx: “take”), inscription (ingredients and their quantities,
strength, or concentration), drug, strength or concentration (dose taken), signature (directions
for use)
-having specific information about why the patient is taking the medication can help the
pharmacist give instructions
-bottom portion: refills (not permitted for Schedule II drugs, max 5 refills or a 6-month
supply), provider signature, DEA number, generic substitutions (write DISPENSE AS WRITTEN)
Electronic Drug Prescriptions or E-Sign
-voids the requirements that prescriptions must be written on paper or printed as a hard copy
-there are financial incentive and penalties via Medicare for prescribing (HCPs that do not
participate will receive a percentage decrease in reimbursement)
Drug Prescribing Etiquette
-federal law stipulates that providers may not write prescriptions for narcotics for
themselves or family members
-there is no law against prescribing for friends, but pharmacist may call and discuss as a
curtesy
-HMOs have begun to watch prescribing practices
-prescriptions refilled regularly, although the patient is not required to return to provider, may
stimulate questions for pharmacists
-drug sample trading between providers; they are responsible for adverse effects
Avoiding Mistakes
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