----------------------------

----------------------------------------------------------------

TO BE PUBLISHED IN THE OFFICIAL REPORTS
 

OFFICE OF THE ATTORNEY GENERAL
 

State of California
 

JOHN K. VAN DE KAMP
 

Attorney General
 

:
 

OPINION : No. 88-303
 

:
 

of : November 3, 1988
 

:
 

JOHN K. VAN DE KAMP :
 

Attorney General :
 

:
 

JACK R. WINKLER :
 

Assistant Attorney General :
 

:
 

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
 

1 88-303
 
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.
 

2 88-303
 
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. 


3 88-303
 
 

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.
 

4 88-303
 
 

"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).
 

5 88-303
 
 

 

(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.
 

6 88-303
 
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
 

7 88-303
 
 

 

 

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
 

Health and Safety Code section 1250 and in like 6 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.
 

8 88-303
 
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 backup 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.
 

9 88-303
 
 

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
 

10 88-303
 
 

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
 

11 88-303
 
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.
 

12 88-303
 
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
 

13 88-303
 
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
 

14 88-303
 
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
 

15 88-303
 
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.
 

16 88-303
 
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. 


* * * * *
 

17 88-303
 
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.
 

18 88-303
 
"(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
 

19 88-303
 
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." 


20 88-303