Court Opinion

ID: 4127425
Source: CourtListenerOpinion
Date Created: 2017-02-18 00:27:15.195553+00
Date Added: 2024-06-11T14:31:32.966332
License: Public Domain

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

                                                    6
Health and Safety Code section 1250 and in like       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 back­
     up 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

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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

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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.

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          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. 

                           * * * * *

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                        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.

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          "(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

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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." 

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