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THE IMMUNIZATION LAW AND POLICY PROGRAM
MILKEN INSTITUTE, SCHOOL OF PUBLIC HEALTH AND HEALTH SERVICES
GEORGE WASHINGTON UNIVERSIY
Standing Orders:
Non-Physician Health Professionals &
Immunization Practice
Alexandra M. Stewart, JD
Fall 2013
This study examines state laws in 2013 that govern the authority of medical assistants, midwives,
different categories of nurses, pharmacists, and physician assistants to engage in immunization
practice either under their own or delegated authority. Additionally, the settings where vaccines
may be administered are identified.
This project was funded by the National Center for Immunization & Respiratory Diseases Immunization Services
Division (NCIRD) of the Centers for Disease Control and Prevention (CDC) under Contract Number 200-201142010. CDC scientists collaborated with GW researchers to design the study and review project findings.
Marisa A. Cox, M.A., MPH, Ricardo Lopez, M.A., MPH, Research Assistant, and Jacqueline E. Miller, Esq., MPH
Immunization Law and Policy Program, Department of Health Policy, Milken Institute, School of Public Health and
Health Services, George Washington University, provided research support.
TABLE OF CONTENTS
SUMMARY OF FINDINGS ......................................................................................................... i
METHODS .................................................................................................................................... 2
ELEMENTS OF IMMUNIZATION PRACTICE ..................................................................... 2
TERMINOLOGY ......................................................................................................................... 4
MEDICAL ASSISTANTS ............................................................................................................ 6
MIDWIVES ................................................................................................................................. 12
NURSES ....................................................................................................................................... 20
PHARMACISTS ......................................................................................................................... 37
PHYSICIAN ASSISTANTS....................................................................................................... 49
SUMMARY OF FINDINGS
This study examines state laws governing the authority of medical assistants, midwives,
different categories of nurses, pharmacists, and physician assistants to: 1) assess a patient’s
immunization status, 2) prescribe one or more vaccines, and 3) administer vaccines either under their
own or delegated authority. Additionally, the permissible patient populations and settings where
vaccines may be administered are identified.
All states have enacted laws permitting physicians to delegate certain medical tasks to nonphysician health professionals. Some states identify the providers who have legal authority to
vaccinate patients. Laws that clearly outline the appropriate process and personnel authorized to
administer vaccines under delegated authority protect providers from exposure to civil and/or
criminal liability. Providers must ensure that the law authorizes patient assessment, prescription, or
administration before proceeding.
Most states have adopted vaccination-specific terminology when describing permissible
practice. Other states reference a variation of “drugs or legend drugs,” or “medications”.
Medical Assistants:
Less than one-third of all states address the ability of medical
assistants to assess or administer medications or vaccines and no state addresses prescription
authority. Most states permitting medical assistants to administer vaccines require a physician,
physician assistant, or a nurse in advanced practice to directly supervise the medical assistant, who
typically must work within the physical boundaries of the provider’s office.
Midwives: In most states, certified midwives who are advanced practice nurses are subject
to collaborative practice agreements and provide health care under the direction of a physician or
protocols developed with a physician. The agreement may authorize a midwife to conduct patient
assessments, write prescriptions, and administer medications in a variety of clinical and office
settings. Several states have restricted the patients who may receive vaccination from midwives,
because the practice of midwifery is limited to women and newborns.
Nurses: This review includes various categories of nurses: 1) Nurses in Advanced Practice:
a) Advanced Practice Nurse, b) Clinical Nurse Specialist, c) Nurse Practitioner; 2) Registered Nurse;
3) Practical Nurse; and 4) Vocational Nurse. Most states permit all categories of nurses to administer
medications under their own or delegated authority. In addition to public and private clinical
settings, nurses may practice in a broad range of community locations.
Pharmacists: All states address how pharmacists may assess, prescribe, and/or administer
vaccines under their own or delegated authority. Approximately half of states permit pharmacists to
administer vaccines to children. Laws governing pharmacists most frequently reference vaccines, or
adult or childhood immunizations. The most commonly identified vaccines are influenza,
pneumococcal, and zoster vaccines. In addition to pharmacies, hospitals, and other health care
facilities, a limited number of states authorize pharmacists to administer vaccines in other settings.
Physician Assistants: All jurisdictions address the authorization of physician assistants to
assess, prescribe, or administer vaccines and the level of required supervision. More than half of the
states permit physician assistants to undertake immunization practice in a broad range of settings
including a wide range of clinical and community locations.
i
A decrease in the number of primary care physicians, coupled with an increase in the
number of patients, requires a shift from physician-centered care to a model that includes sharing
responsibility with non-physician health professionals. Delegating preventive services to nonphysician health professionals is a proven strategy to increase a physician’s ability to provide
high quality care to more patients. 1 Because the provision of vaccination services constitutes the
conduct of medical practice, vaccine delivery is under the sole control of a physician and
requires formal authorization in order for non-physicians to perform any procedure that
constitutes medical practice.
This study examines state laws governing the authority of medical assistants, midwives,
different categories of nurses, pharmacists, and physician assistants to: 1) assess a patient’s
immunization status, 2) prescribe one or more vaccines, and 3) administer vaccines either under their
own or delegated authority. Additionally, the settings where vaccines may be administered are
identified.
METHODS
Using a standard legal research database, researchers identified medical and health
professional practice acts and other relevant statutes and regulations, attorneys general opinions,
judicial decisions, and professional licensing board decisions from fifty states and the District of
Columbia (for purposes of this project the District of Columbia is considered a state). The data
were analyzed to determine how the three elements of immunization practice were addressed:
patient assessment, prescriptions for vaccines, and administration of vaccines. We also
determined whether specific vaccines were identified, the permissible patient populations, and
the permissible practice settings.
ELEMENTS OF IMMUNIZATION PRACTICE
The process of vaccinating an individual requires three separate activities:
1) Assessment of a patient’s immunization status: Assessment may include screening,
examining, diagnosing, or treating the patient. It does not include merely collecting or reporting
data, taking a patient’s history, or interviewing patients.
2) Prescription for one or more vaccines: Prescribing is oral, written, or electronic, and
excludes simply transmitting a prescription issued by another provider.
3) Administration of one or more vaccines: Vaccines may be administered by injection,
orally, or nasally. Administration does not include dispensing medication. Dispensing refers to
the preparation, packaging, labeling, record keeping, and transfer of a prescription drug to a
patient or an intermediary, who is responsible for administration of the drug. 2
1
Altschuler, J. et al. “Estimating a Reasonable Patient Panel Size for Primary Care Physicians with Team-Based
Task Delegation.” Annals of Family Medicine. Vol. 10, No. 5. Oct. 2012.
2
Mosby's Medical Dictionary, 8th edition. © 2009
2
THE ROLE OF STATE LAW IN REGULATING IMMUNIZATION PRACTICE
All states have enacted laws permitting physicians to delegate certain medical tasks to
non-physician health professionals. Some laws identify the providers who have legal authority
to vaccinate patients, while in other cases, the law is silent. Laws that clearly outline the
appropriate process and personnel who may assess a patient’s vaccination status, prescribe
vaccines, and administer vaccines will protect providers from exposure to civil and/or criminal
liability. All providers who engage in any aspect of immunization practice must ensure that the
law permits the activities before proceeding.
The following excerpt from a 1997 case decided by the Appellate Court of Illinois,
demonstrates the importance of establishing legal authorization before delegating medical care to
non-physician personnel. A medical assistant (MA) had attended an educational program for
MAs, taken additional relevant university classes, and further courses in a registered nurse
program, all outside of Illinois. She had worked for multiple medical practices in Illinois for
more than two decades, where a supervising physician instructed her to administer vaccines.
She was convicted of practicing nursing without a license, in violation of the state’s
Nursing Act. She was sentenced to one year of supervision, was levied a $250.00 fine, and was
required to perform 60 hours of public service employment.
While the court recognized that the MA had the ability and qualifications to perform the
tasks, the court was unable to identify any provision in state law that outlined the functions of a
medical assistant. The lack of explicit legal permission required the court to find the MA had
acted outside the scope of her authority, even though the supervising physician had provided
instruction, other supports, and remained on site:
Dr. Kovacevic explained that, as a medical assistant, Stults performed . . . immunizations, during
which he supervised her. In explaining what he meant by “supervision,” Dr. Kovacevic stated that
supervision meant that he filled the needle, told Stults what to do, and then was somewhere in the
office while Stults gave the immunization. . . . We find no Illinois statute that defines what a
medical assistant is or designates what functions a medical assistant is able to perform. . . .
[W]e find that the legislature carefully provided for assistants to medical personnel where it
deemed assistants were warranted. . . . Therefore, because no statute provides that medical
assistants may perform some of the same functions as nurses, Stults' performing the various
nursing duties, even as a medical assistant, was in violation of the Nursing Act. . . . A person
without a nursing license may not evaluate, treat, or counsel the ill, infirmed, or injured and may
not administer medication to others. People v. Stults, 683 N.E.2d 521 (Ill. App. Ct. 1997)
3
TERMINOLOGY
Delegation of Medical Care
State laws delineating the authority of a medical provider to delegate identified medical
tasks to a non-physician healthcare professional are described using different terminology and
have been included in our research: 1) “with collaboration,” 2) “collaborative practice,” 3)
“collaborative practice agreement,” 4) “collaborative authority,” 5) “collaborating” provider, 6)
“delegated authority,” 7) “delegation order,” 8) “delegation agreement,” or 9) indicating acts that
may be “delegated” from one provider to another. Additionally, a state’s law may indicate that
certain acts may only be performed with a prescription or with “prescriptive authority” or under
a “prescriptive agreement”.
Some states permit the delegation of health care through standardized procedures termed
“standing orders”. Standing orders allow non-physician clinical personnel to assess patients and
administer vaccines without a patient-specific order. Standing orders describe the specific type
of medical practice that will be delegated, delineate the procedures that personnel must follow,
identify the patient population that may be served, specify the level of physician supervision
required, and govern the settings where services may occur.
Adoption of Non Immunization-Specific Terms
Several states use non-specific terms when addressing the authority of non-physicians to
assess, prescribe, or administer vaccines. The following examples can describe vaccines and
immunizations and have been included in our research: 1) diagnostic or therapeutic regimens, 2)
drug or device by injection, 3) legend drug 3 /substances, 4) medications, 4 5) pharmacological
agents, 6) prescription drugs or devices, 7) Schedule VI controlled substances, or 8) therapeutic
measures.
Adoption of Immunization-Specific Terms
Forty-nine states have adopted immunization-specific terminology when describing
permissible practice among the 10 categories of health professionals under review. See Table 1
below.
3
Legend drugs have been included because they are approved by the U.S. Food and Drug Administration (FDA)
and are required by federal or state law to be dispensed to the public only when a licensed physician or other
licensed provider prescribes them. A legend drug can be a controlled substance (narcotic), or a non-narcotic
“Legend Drug Law and Legal Definition.” USLegal.com. Available at: http://definitions.uslegal.com/l/legenddrug/.
4
Medication is a general term that includes drugs and pharmaceuticals. Medications may be administered by
injection or other methods.
4
Sixteen of 48 states apply immunization-specific language to only one category of health
professional: fifteen of these states refer to pharmacists (Alabama, Arizona, Delaware, Florida,
Idaho, Kansas, Louisiana, Nevada, North Carolina, North Dakota, Ohio, Rhode Island, South
Carolina, West Virginia, and Wyoming). Michigan and Texas are the two states that use
immunization-specific terms for all 11 categories of professionals.
TABLE 1
PROFESSIONAL
Medical Assistant
STATES USING IMMUNIZATION-SPECIFIC LANGUAGE
STATE
Alaska, Georgia, Maryland, Michigan, Montana, Texas, Washington
Massachusetts, Michigan, Mississippi, New York, Pennsylvania, Texas,
Midwife
Vermont, Washington
Connecticut, District of Columbia, Hawai’i, Illinois, Iowa, Kentucky,
Advanced Practice Nurse
Michigan, Texas
Michigan, Mississippi, South Dakota, Texas
Clinical Nurse Specialist
Alaska, California, Massachusetts, Michigan, Mississippi, New York,
Nurse Practitioner
Oregon, Pennsylvania, South Dakota, Texas, Washington
Connecticut, Georgia, Indiana, Maine, Massachusetts, Michigan,
Practical Nurse
Mississippi, Pennsylvania, Tennessee, Texas, Virginia, Washington
Alaska, Arkansas, California, Colorado, Connecticut, Georgia, Illinois,
Indiana, Iowa, Maine, Massachusetts, Michigan, Minnesota, Mississippi,
Registered Nurse
Missouri, New Hampshire, New Jersey, New Mexico, New York, Oregon,
Pennsylvania, Texas, Virginia, Washington
California, Michigan, Texas
Vocational Nurse
Alabama, Arizona, Arkansas, California, Colorado, Connecticut,
Delaware, District of Columbia, Florida, Georgia, Hawai’i, Idaho, Illinois,
Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland,
Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New
Pharmacist
Hampshire, New Jersey, New Mexico, New York, North Carolina, North
Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South
Carolina, South Dakota, Texas, Vermont, Virginia, Washington, West
Virginia, Wisconsin, Wyoming
California, Colorado, Hawai’i, Illinois, Iowa, Massachusetts, Michigan,
Physician Assistant
Oklahoma, Oregon, South Dakota, Texas, Wisconsin
Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice – Fall 2013
5
MEDICAL ASSISTANTS
Fifteen states address the ability of medical assistants (MAs) to assess patients or
administer drugs, medications or vaccines either through statute or case law. These states are:
Alaska, Arizona, Arkansas, California, Florida, Georgia, Maryland, Michigan, Montana, New
Jersey, South Dakota, Texas, and Washington. Illinois and Wyoming address MAs’ scope of
practice only in case law, which showed that: Illinois prohibits MAs from practicing in the state
and Wyoming permits MAs to routinely inject medications. See Table 2 and Figure 1 below.
Authority to Assess Patient Status
Five states address patient assessments (Arizona, Illinois, Maryland, South Dakota, and
Texas). Arizona, South Dakota, and Texas allow MAs to conduct assessments under delegated
authority, while Illinois and Maryland prohibit assessments. Excerpts from Texas and Maryland
follow:
[S]tanding delegation orders may include authority to undertake the following . . . (1) the taking of
personal and medical history; (2) the performance of appropriate physical examination and the
recording of physical findings . . . 22 Tex. Admin. Code § 193.4 (2012) Scope of Standing
Delegation Orders
***
A. A physician may not delegate to an assistant technical acts which are exclusively limited to any
individual required to be licensed, certified, registered, or otherwise recognized pursuant to any
provision of the Health Occupations Article and the Education Article, Annotated Code of
Maryland. . . . Code of Md. Regs. 10.32.12.04 (2012) Scope of Delegation; Code of Md. § 19-114
(2013) Definitions; Code of Md. § 19-3B-01 (2013) Definitions
Authority to Prescribe Vaccines
No state addresses whether MAs may prescribe any drugs, medication, or vaccine either
under their own or delegated authority.
Authority to Administer Vaccines
Fourteen of the 15 states permit MAs to administer drugs, injections, medications, or
vaccines, but only under delegated authority (Alaska, Arizona, Arkansas, California, Florida,
Georgia, Maryland, Michigan, Montana, New Jersey, South Dakota, Texas, Washington, and
Wyoming). An example from Washington’s statute is below:
(4) A medical assistant-registered may perform the following duties delegated by, and under the
supervision of, a health care practitioner . . . (f) Administering . . . vaccines, including combination or
multidose vaccines. . . . Rev. Code of Wash. 18.360.050, amended by 2013 Wash. Legis. Serv. Ch. 128
(S.H.B. 1515) (2013) Medical assistant-certified—Authorized delegated duties
Four state courts have addressed vaccine administration and MAs (Illinois, Georgia,
Maryland, and Wyoming). Of the 4 decisions, Illinois is the only state that explicitly prohibits
medical assistants from conducting any element of immunization practice. The court held that “a
6
person without a nursing license may not evaluate, treat, or counsel the ill, infirmed, or injured
and may not administer medication to others.” 5 In cases in Georgia, 6 Maryland, 7 and
Wyoming, 8 MAs routine administration of injectable medications or vaccines was determined to
be within the scope of the MAs’ practice.
Defining Patients who may Receive Vaccinations
No state specifies the age range of patients who may receive vaccinations or other
medications from MAs.
Level of Supervision Required to Practice
Thirteen states address the level of supervision MAs require (Alaska, Arizona, Arkansas,
California, Florida, Georgia, Maryland, Michigan, Montana, New Jersey, South Dakota, Texas,
and Washington). In some states, MAs must be “directly” supervised. Other states include
additional directives related to supervisor proximity to the MA while a vaccine is administered.
Finally, states may specify only that MAs must be supervised.
Arizona, Florida, and South Dakota require direct supervision. However, the obligations
of the supervisor are not defined. Florida and South Dakota limit supervision authority to
licensed physicians, while Arizona permits physician assistants or nurse practitioners to
supervise MAs. An excerpt from Arizona is below:
A. A medical assistant may perform the following medical procedures under the direct supervision
of a doctor of medicine, physician assistant or nurse practitioner . . . 2. Administer injections.
Ariz. Rev. Stat. § 32-1456 (2012) Medical assistants; use of title; violation; classification
Four of the 13 states require the supervising physician, physician assistant, or advanced
practice nurse to remain on-site during the administration of a vaccine (Alaska, Maryland,
Montana, and New Jersey). Montana and New Jersey illustrate this policy:
(2) Medical assistants shall work under the supervision of a Montana-licensed physician or
podiatrist who is responsible for assigning administrative and clinical tasks to the medical assistant
relating to the physician or podiatrist's practice of medicine. (3) Physician or podiatrist
supervision shall be active and continuous but does not require the physical presence of the
supervising physician or podiatrist at the time and place that services are rendered so long as the
physician or podiatrist is available for consultation, except that physician or podiatrist supervision
shall be onsite when a medical assistant performs: (a) invasive procedures; (b) administers
medicine; or (c) performs allergy testing. . . . (7) The following tasks may not be assigned to a
medical assistant: (a) any [invasive] procedures, including injections other than immunizations. . .
. Admin. Rules of Mont. 24.156.640 (2012) Medical Assistant
5
People v. Stults, 683 N.E.2d 521 (Ill. App. Ct. 1997)
Kerr v. OB/GYN Associates of Savannah et al., 314 Ga.App. 40, 723 S.E.2d 302 (2012)
7
Community Clinic, Inc. et al. v. Department of Health and Mental Hygiene et al., 174 Md.App. 526, 922 A.2d 607.
(2007)
8
Beavis v. Campbell County Memorial Hospital, 20 P.3d 508 (2001)
6
7
***
4. The physician shall remain on the premises at all times that treatment orders for injections are
being carried out by the assistant and shall be within reasonable proximity to the treatment
room and available to observe, assess and take any necessary action regarding effectiveness,
adverse reaction or any emergency. 5. The certified medical assistant shall wear a clearly visible
identification badge indicating his or her name and credentials. . . . N.J. Admin. Code 13:35-6.4
(2012) Delegation of administration of subcutaneous and intramuscular injections to certified
medical assistants
Arkansas is the only state that leaves the level of supervision to the discretion of the
physician. An excerpt from the law is below:
Section 2. Procedures for Delegating a Medical Practice A. Prior to delegating a medical practice
or task, the physician shall determine the following: . . . 3) The appropriate level of supervision
for the Physician to exercise while the medical practice or task is being performed. . . . Ark.
Admin. Code § 060.00.1-31 (2012) Physician Delegation Regulation
Five of the 13 states indicate only that MAs must be supervised (California, Georgia,
Michigan, Texas, and Washington). Quotes from Michigan and California are below. In
California, specific authorization is required and Michigan requires only physician direction:
(a)(1) Notwithstanding any other provision of law, a medical assistant may administer medication
only by intradermal, subcutaneous, or intramuscular injections and perform skin tests and
additional technical supportive services upon the specific authorization and supervision of a
licensed physician and surgeon or a licensed podiatrist. . . . Cal. Business and Professions Code §
2069 (2012) Medical assistants; authorized tasks under direction of certain medical
professionals; delegation of supervision; definitions; inpatient care in general acute care
hospitals prohibited; section not to be constructed to authorize medical assistants to perform
certain tasks or nurse practitioner, nurse- midwife or physician assistant to be a laboratory
director of a clinical laboratory
***
A health professional other than a physician may administer an immunizing agent as long as the
agent is being administered under the direction of a physician. Mich. Comp. Laws 333.9204
(2013) Person who may administer immunizing agent
Settings where Medical Assistants are Authorized to Vaccinate
Six states identify the settings where the MA may perform (Alaska, Arkansas, California,
Georgia, Texas, and Washington). Alaska permits MAs to practice in any private or public
ambulatory care setting:
(b) . . . The certified medical assistant may only perform the delegated duty in a private or public
ambulatory care setting. . . . 12 Alaska Admin. Code § 44.966 (2012) Delegation of the
administration of injectable medication
8
Arkansas, Georgia, Texas, and Washington allow MAs to provide services in the
delegating physician’s office. Arkansas requires the MA to work within the physical boundaries
of the office as shown below:
Section 3. Additional Requirements for Delegating the Administration of Drugs . . . . B.
Administration of drugs, delegated pursuant to this Regulation, shall only be permissible within
the physical boundaries of the delegating physician's offices . . . Ark. Admin. Code § 060.00.1-31
(2012) Physician Delegation Regulation
California permits MAs to work in licensed clinics:
(a)(1) Notwithstanding any other provision of law, a medical assistant may administer medication
only by intradermal, subcutaneous, or intramuscular injections and perform
skin tests and
additional technical supportive services upon the specific authorization and supervision of a
licensed physician and surgeon or a licensed podiatrist. A medical assistant may also perform all
these tasks and services in a [licensed] clinic . . . upon the specific authorization of a physician
assistant, a nurse practitioner, or a nurse-midwife.
Cal. Business and Professions Code § 2069
(2012) Medical assistants; authorized tasks under direction of certain medical professionals;
delegation of supervision; definitions; inpatient care in general acute care hospitals prohibited;
section not to be constructed to authorize medical assistants to perform certain tasks or nurse
practitioner, nurse-midwife or physician assistant to be a laboratory director of a clinical
laboratory
In Texas, MAs may provide services at facilities licensed by the State Board of
Pharmacy:
(c) A physician may also delegate to any qualified and properly trained person acting under the
physician's supervision the act of administering or providing dangerous drugs through a facility
licensed by the Texas State Board of Pharmacy, as ordered by the physician, that are used or
required to meet the immediate needs of the physician's patients. . . . Tex. Stat. & Codes §
157.002 (2012) General Delegation of Administration and Provision of Dangerous Drugs; see
also Tex. Stat. & Codes § 563.051 (2012) General Delegation of Administration and Provision
of Dangerous Drugs
Washington allows MAs to perform their duties at group practices, “other health care
facilities,” and rural and small medical practices and clinics:
The legislature finds that medical assistants are health professionals specifically trained to work in
settings such as physicians' offices, clinics, group practices, and other health care facilities. . . .
The legislature further finds that rural and small medical practices and clinics may have limited
access to formally trained medical assistants. . . . Rev. Code of Wash. 18.360.005, amended by
2013 Wash. Legis. Serv. Ch. 128 (S.H.B. 1515) (2013) Findings
9
Table 2: STANDING ORDERS: Medical Assistants & Immunization Practice
STATE
Alaska
Arizona
Arkansas
California
Florida
Georgia
Illinois
Maryland
Michigan
Montana
N Jersey
S Dakota
Texas
Washington
Wyoming
Own
Authority
Assessment
Delegated
Authority
Prohibited
Own
Authority
Prescription
●
●
●
Delegated
Authority
Prohibited
Own
Authority
Administration
Delegated
Authority
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Prohibited
Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice—Fall 2013
10
●
Figure 1 – Medical Assistants
Medical Assistants are most frequently permitted to administer immunizations or
injectable medications, followed by medications and drugs. No state identifies specific vaccines.
Drugs or Legend Drugs/Substances
Arkansas
Maryland (oral)
Texas
Washington
Medications
Arizona
Florida
Illinois (prohibited)
Montana
South Dakota
Washington
Immunizations or Vaccines
Alaska
Georgia
Illinois (prohibited)
Maryland
Michigan
Montana
Texas
Washington
Injectable Medication/Inoculation
Alaska
Arizona
California
Georgia
Maryland
New Jersey
Wyoming
11
MIDWIVES
Midwives practice in all states under a variety of titles. Titles that appear in state laws
include: certified nurse midwife, registered nurse midwife, nurse midwife, midwife, and
traditional midwife. New Hampshire is the only state where physician assistants may be
authorized to practice midwifery. See Table 3 and Figure 2 below.
Forty-nine states address whether midwives may assess, prescribe, or administer drugs,
medications, or vaccines. The laws in Oregon and Rhode Island do not address any of the
elements of immunization practice for midwives.
Authority to Assess Patient Status
Forty-five states allow midwives to conduct patient assessments under their own
authority. Twenty-eight of the 45 states also permit the practice under delegated authority. No
state prohibits midwives from conducting patient assessments. Six states do not address this
element of immunization practice (Kentucky, Michigan, New Jersey, Oregon, Pennsylvania, and
Rhode Island).
The excerpt from Utah shows that a collaborative agreement between a certified nurse
midwife and a physician must be established in order for the midwife to conduct assessments:
9) “Practice as a certified nurse midwife” . . . (b) . . . includes: (i) having a safe mechanism for
obtaining medical consultation, collaboration, and referral with one or more consulting physicians
who have agreed to consult, collaborate, and receive referrals, but who are not required to sign a
written document regarding the agreement . . . (iii) maintaining written documentation of the
parameters of service for independent and collaborative midwifery management and transfer of
care when needed . . . (c) the authority to: (i) elicit and record a patient's complete health
information, including physical examination . . . (ii) assess findings and upon abnormal findings
from the history, physical examination . . . collaborate with the consulting physician or another
qualified physician, or refer the patient to the consulting physician or to another qualified
physician as appropriate; (iii) diagnose, plan, and implement appropriate patient care, including
the administration and prescribing of: (A) prescription drugs. . . . Utah Code § 58-44a-102
(2012) Definitions
Authority to Prescribe Vaccines
Forty-four states address how midwives may prescribe drugs, medications, or vaccines
under their own authority or through delegation. Seventeen states permit midwives to prescribe
under their own license. Thirty states authorize midwives to prescribe under delegated authority.
Montana, Tennessee, and Vermont are the three states that grant both independent and delegated
prescription authority.
Eight states do not address this element of immunization practice
(Arizona, Arkansas, Connecticut, Michigan, Nebraska, Nevada, Oregon, and Rhode Island).
Arizona and Minnesota have adopted different policies related to prescription authority
for different categories of midwives. Arizona permits certified nurse midwives to prescribe
legend drugs under their own authority. In contrast, Minnesota allows certified nurse midwives
12
to prescribe only under delegated authority. Traditional midwives in Minnesota “shall not
prescribe, [or] dispense . . . prescription drugs”.
The following provisions from Alabama and Pennsylvania illustrate how
midwives may prescribe drugs and vaccines within a collaborative agreement. Examples
from the District of Columbia and New Mexico authorize midwives to prescribe
medications and dangerous drugs under their own authority:
(a) . . . [C]ertified nurse midwives, engaged in collaborative practice with physicians practicing
under protocols approved in the manner prescribed by this article may prescribe legend drugs to
their patients. . . . Code of Ala. § 34-21-86 (2012) Prescribing legend drugs; initiating call-in
prescriptions; administering legend drugs
***
(5) A nurse-midwife may, in accordance with a collaborative agreement with a physician, and
consistent with the nurse-midwife's academic educational preparation and National certification by
the AMCB or its successor organizations, prescribe, dispense, order and administer . . .
immunizing agents . . . and preventative measures. 49 Pa. Admin. Code § 18.6 (2012) Practice
of midwifery
***
[T]he nurse-midwife may perform any of the acts listed below, including: . . . (h) Prescribe
appropriate medications . . . (j) Provide primary health care . . . 17 Dist. of Columbia Municipal
Regs. § 5808 (2012) Scope of Practice
***
16.11.2.10 PRACTICE OF THE CERTIFIED NURSE-MIDWIFE: A. Scope of practice:
midwifery practice as conducted by a CNM is the independent management of women's health
care, focusing particularly on common primary care issues . . . . A CNM independently
prescribes, distributes and administers dangerous drugs and devices appropriate to a client's
condition. . . . . B. Prescriptive authority. (1) . . . (a) A CNM may independently prescribe,
distribute or administer dangerous drugs and devices appropriate to a client's condition. . . . N.M.
Admin. Code 16.11.2 (2012) Certified Nurse Midwives
Authority to Administer Vaccines
Forty-seven states address whether midwives may administer medications and/or
vaccines. Eighteen of the 47 states permit midwives to administer under their own license and
44 allow administration under delegation. Fifteen states permit administration under both
categories of authority. The four states that do not address administration duties are New Jersey,
North Carolina, Oregon, and Rhode Island.
Various levels of midwives in Arizona and Minnesota are granted different categories of
authority related to administration of medications. As seen below, in Arizona, certified nurse
midwives may administer legend drugs under independent authority, while midwives in the state
are prohibited from doing so. Minnesota’s rules are more restrictive for traditional midwives
than those that apply to certified nurse midwives:
CERTIFIED NURSE MIDWIFE
A. The Board recognizes the following APRN roles: 1. Registered nurse practitioner (RNP) in a
population focus including Certified Nurse Midwife as a population focus of RNP. . . . Ariz.
13
Admin. Code R4-19-501, amended by 2013 AZ REG TEXT 311810 (2013) Roles and Population
Foci of Advanced Practice Registered Nursing (APRN); Certification Programs
15. "Registered nurse practitioner" means a professional nurse who . . . (d) Has an expanded
scope of practice within a specialty area that includes: . . . (v) . . . administering and dispensing
therapeutic measures, including legend drugs . . . within the scope of registered nurse practitioner
practice . . . Ariz. Rev. Stat. § 32-1601 (2012) Definitions
A. An RNP . . . may: 1. Prescribe drugs and devices. . . . Ariz. Admin. Code R4-19-512 (2012)
Prescribing Drugs and Devices
MIDWIFE
D. A midwife shall not administer drugs or medications except as provided in [referenced citations
in other parts of the law that do not include any reference to vaccines or immunizations]. . . . Ariz.
Admin. Code § R9-16-108 (2012) Prohibited Practice; Transfer of Care
***
Subdivision 1. Certified nurse-midwives. A certified nurse-midwife may prescribe and
administer drugs and therapeutic devices within practice as a certified nurse-midwife. . . . Minn.
Stat. § 148.235 (2012) Prescribing drugs and therapeutic devices
Subd. 9. Traditional midwifery services. “Traditional midwifery services” means the assessment
and care of a woman and newborn during pregnancy, labor, birth, and the postpartum period
outside a hospital. . . . Minn. Stat. § 147D.01 (2012) Definitions
(a) A licensed traditional midwife shall not prescribe, dispense, or administer prescription drugs,
except as permitted under paragraph (b). (b) A licensed traditional midwife may administer
vitamin K either orally or through intramuscular injection, postpartum antihemorrhagic drugs
under emergency situations, local anesthetic, oxygen, and a prophylactic eye agent to the newborn
infant. . . . Minn. Stat. § 147D.09 (2012) Limitations of practice
The provisions below from New Mexico and Washington show how midwives may
administer drugs. Note that Washington limits administration authority to specific vaccines:
The licensed midwife may provide care to women without general health or obstetrical
complications. . . . Such care includes . . . (4) Well-woman care . . . (6) Administration of specific
drugs and medications as outlined in the Mexico Midwives Association Policies and Procedures . .
. . N.M. Admin. Code 16.11.3 (2012) Licensed Midwives
***
A midwife licensed under this chapter may . . . administer such other drugs or medications as
prescribed by a physician. . . . Rev. Code of Wash. 18.50.115 (2012) Administration of drugs
and medications—Rules
(2) . . . [L]icensed midwives may obtain and administer the following medications . . . (e) Measles,
Mumps, and Rubella (MMR) vaccine to nonimmune postpartum women, HBIG and HBV for
neonates born to hepatitis B+ mothers. . . . Wash. Admin. Code 246-834-250 (2012) Legend
drugs and devices
14
Defining Patients who may Receive Vaccinations
Eleven states have restricted the patients who may receive vaccinations from midwives
(Arkansas, Massachusetts, Minnesota, Montana, New Hampshire, New York, Ohio, Oklahoma,
Pennsylvania, Washington, and Wisconsin).
Because the practice of midwifery is necessarily limited to women and newborns,
midwives have fewer opportunities to provide vaccines to a full range of patient populations.
The following selections from Washington and Wisconsin outline a typical explanation of the
scope of practice for midwives and the patients who may receive vaccines:
(B) . . . (iv) “Practice of nurse midwifery” means the performance for compensation of nursing
skills relevant to the management of women's health care, focusing on pregnancy, childbirth, the
postpartum period, care of the newborn, family planning, and gynecological needs of women,
within a health care system that provides for consultation, collaborative management, or referral as
indicated by the health status of the client . . . . Ark. Code § 17-87-102 (2012) Definitions; see
also Ark. Admin. Code 067.00.1-II (2012) The Practice of Nursing
***
(2) . . . [L]icensed midwives may obtain and administer the following medications . . . (e) Measles,
Mumps, and Rubella (MMR) vaccine to nonimmune postpartum women, HBIG and HBV for
neonates born to hepatitis B+ mothers. . . . Wash. Admin. Code 246-834-250 (2012) Legend
drugs and devices
***
(1) The scope of practice is the overall management of women's health care, pregnancy, childbirth,
postpartum care for newborns, family planning, and gynecological services consistent with the
standards of practice of the American College of Nurse-Midwives and the education, training, and
experience of the nurse-midwife. (2) The nurse-midwife shall collaborate with a physician with
postgraduate training in obstetrics pursuant to a written agreement with that physician. . . . Wis.
Admin. Code N 4.06 (2012) Scope of practice
Level of Supervision Required to Practice
In 38 states certified nurse midwives who are advanced practice nurses are subject to
collaborative practice agreements and provide health care under the direction of a physician or
protocols developed with a licensed physician. The agreement authorizes categories of care,
treatment, or procedures to be performed by the midwife and the conditions for their
performance (Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida,
Georgia, Illinois, Indiana, Kansas, Louisiana, Maine, Michigan, Minnesota, Mississippi,
Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New York, North
Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota,
Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin).
15
The laws in Kansas and Massachusetts are examples of the performance expectations for
both the physician and the midwife engaged in collaborative practice:
Each [nurse midwife] shall be authorized to make independent decisions about advanced practice
nursing needs of families, patients, and clients and medical decisions based on the authorization
for collaborative practice with one or more physicians. . . . Kan. Admin. Regs. 60-11-101 (2012)
Definition of expanded role; limitations; restrictions
(a) Each written protocol that [a nurse midwife] is to follow when prescribing, administering, or
supplying a prescription-only drug . . . . Kan. Admin. Regs. 60-11-104a (2012) Protocol
requirements; prescription orders
Each advanced practice registered nurse in the role of nurse-mid-wife . . . shall be authorized to
perform the following: (a) Provide independent nursing diagnosis . . . and treatment . . . (b)
develop and manage the medical plan of care for patients or clients, based on the authorization for
collaborative practice . . . . Kan. Admin. Regs. 60-11-105 (2012) Functions of the advanced
practice registered nurse in the role of nurse-midwife
(d) [a nurse midwife] may prescribe drugs pursuant to a written protocol as authorized by a
responsible physician. Each written protocol shall contain a precise and detailed medical plan of
care for each classification of disease or injury for which the advanced registered nurse
practitioner is authorized to prescribe and shall specify all drugs which may be prescribed by the
advanced registered nurse practitioner. . . . Kan. Stat. 65-1130 (2012) Advanced practice nurse;
standards and requirements for licensure; rules and regulations; roles, titles and abbreviations;
prescription of drugs authorized; licensure of currently registered individuals
***
(4) Physician Supervision of [a Nurse Midwife] Engaged in Prescriptive Practice. (a) A
supervising physician shall review and provide ongoing direction for the [nurse midwife’s]
prescriptive practice in accordance with written guidelines mutually developed and agreed upon
with the [nurse midwife] . . . and the regulations of the Board of Registration in Nursing . . . . This
supervision shall be provided as is necessary, taking into account the education, training and
experience of the [nurse midwife], the nature of the [midwife’s] practice, and the physician's
availability to provide clinical backup to ensure that the [nurse midwife] is providing patient care
in accordance with accepted standards of practice. (b) A supervising physician shall sign
prescriptive practice guidelines only with those [midwives] for whom he or she is able to provide
supervision . . . and (3), taking into account factors including, but not limited to geographical
proximity, practice setting, volume and complexity of the patient population, and the experience,
training and availability of the supervising physician and the [midwifes]. 243 Code of Mass.
Regs. 2.10 (2012) Advanced Practice Nurse (APN) Eligible to Engage in Prescriptive Practice
In Illinois, supervising physicians who have entered into a collaborative agreement with a
midwife (who is considered an advanced practice nurse in the state), shall not be responsible for
the “acts or omissions” of the midwife unless the physician “has reason to believe” the midwife
is incompetent or commits “willful and wanton misconduct”:
(e) A physician shall not be liable for the acts or omissions of a[n] . . . advanced practice nurse
solely on the basis of having signed a supervision agreement or guidelines or a collaborative
agreement, an order, a standing medical order, a standing delegation order, or other order or
guideline authorizing a[n] . . . advanced practice nurse to perform acts, unless the physician has
reason to believe the . . . advanced practice nurse lacked the competency to perform the act or acts
or commits willful and wanton misconduct.
(f) A collaborating physician may, but is not required to, delegate prescriptive authority to an
16
advanced practice nurse as part of a written collaborative agreement, and the delegation of
prescriptive authority shall conform to the requirements of Section 65-40 of the Nurse Practice
Act. . . . 225 Ill. Compiled Stat. 60/54.5 (2012) Physician delegation of authority to physician
assistants and advanced practice nurses
(a) A collaborating physician or podiatrist may, but is not required to, delegate prescriptive
authority to an advanced practice nurse as part of a written collaborative agreement. This authority
may, but is not required to, include prescription of, selection of, orders for, administration of,
storage of, acceptance of samples of, and dispensing over the counter medications, legend drugs . .
. and other preparations, including, but not limited to, botanical and herbal remedies. . . . 225 Ill.
Compiled Stat. 65/65-40 (2012) Written collaborative agreement; prescriptive authority
Settings where Midwives are Authorized to Vaccinate
Typically, state laws do not identify clinical and office settings where midwives are
authorized to practice. However, 9 states have included provisions outlining the settings where
midwives may practice (Illinois, Indiana, Iowa, Maryland, Massachusetts, Nebraska, North
Dakota, Texas, and Wisconsin).
Midwives may practice in settings including: hospitals,
ambulatory surgical treatment centers, physicians’ offices, private practice, or any setting.
Maryland permits midwives to practice in a nonprofit medical facility or clinic; health
center operating on the campus of an institution of higher learning; public health facility; medical
facility under contract with a state or local health department; or facility funded with public
funds. Nebraska’s law incorporates many of the typical settings where midwives may practice:
(3) A certified nurse midwife may perform authorized medical functions only in the following
settings: (a) In a licensed or certified health care facility as an employee or as a person granted
privileges by the facility; (b) In the primary office of a licensed practitioner or in any setting
authorized by the collaborating licensed practitioner, except that a certified nurse midwife shall
not attend a home delivery; or (c) Within an organized public health agency. . . . Rev. Stat. of
Neb. § 38-613 (2012) Permitted practice described in practice agreement; supervision; settings;
subject to review by board; rules and regulations
17
STATE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Mass.
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
N Hamp.
N Jersey
N Mexico
N York
N Carolina
N Dakota
Ohio
Oklahoma
Oregon
Penn.
R Island
S Carolina
S Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
W Virginia
Wisconsin
Wyoming
`
-Table 3: STANDING ORDERS: MIDWIVES & Immunization Practice
ASSESSMENT
PRESCRIPTION
ADMINISTRATION
Own
Delegated
Own
Delegated
Own
Delegated
Prohibited
Prohibited
Prohibited
Authority
Authority
Authority
Authority
Authority
Authority
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Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice—Fall 2013
18
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Figure 2 - Midwives
Most frequently, states permit at least one category of midwife to administer medications,
followed by immunizations or vaccines.
Drugs or Legend
Drugs/Substances
Alabama
Arizona
California
Hawai’i
Illinois
Kansas
Maine
Massachusetts
Minnesota
Missouri
New Hampshire
New Mexico
North Dakota
South Carolina
Texas
Utah
Washington
Wisconsin
Medications
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Iowa
Kentucky
Maine
Maryland
Minnesota
Mississippi
Missouri
Montana
Nevada
New Hampshire
New Mexico
North Dakota
Ohio
Oklahoma
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
West Virginia
Wyoming
Immunizations or Vaccines
Alaska
Arkansas
California
Colorado
Hawai’i
Illinois
Indiana
Iowa
Kentucky
Maine
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
New Hampshire
New York
Pennsylvania
Tennessee
Texas
19
Virginia
Washington
Injectable
Medication/Inoculation
Alaska
Maryland
Virginia
Pharmacological Agents
Hawai’i
Idaho
Therapeutic
Measure/Regimen
Hawai’i
Maryland
HBIG
Washington
Hepatitis B
Tennessee (case law)
Washington
Influenza
California
Connecticut
Georgia
Massachusetts
MMR
Washington
Pneumococcal
California
Connecticut
Rubella
Vermont
NURSES
This review included various categories of nurses including: 1) Nurses in Advanced
Practice: a) Advanced Practice Nurse, b) Clinical Nurse Specialist, c) Nurse Practitioner, 2)
Registered Nurse, 3) Practical Nurse, and 4) Vocational Nurse. All states address the ability of
at least one category of nurse to assess, prescribe, or administer vaccines. See Tables 3, 4, 5 and
Figures 3, 4, 5, 6, 7 below.
Authority to Assess Patient Status
Nurses in Advanced Practice
Forty-nine states address assessment authority for nurses in advanced practice. Kentucky
and Michigan are the two states that do not reference the practice. Forty-eight states (excluding
Pennsylvania) permit advanced practice nurses to conduct patient assessments under their own
license. Thirty-two states authorize patient assessments under delegated authority. No state
prohibits assessments. The examples from Alabama describe how nurse practitioners may
conduct assessments:
(1) The certified registered nurse practitioner is responsible and accountable for the continuous
and comprehensive management of a broad range of health services . . . with physician
collaboration. . . . These services include but are not restricted to the following: (a) Evaluate
current health status and risk factors of individuals based on comprehensive health history and
comprehensive physical examinations and assessments. (b) Formulate a working diagnosis,
develop and implement a treatment plan, evaluate and modify therapeutic regimens to promote
positive patient outcomes. . . . Ala. Admin. Code r. 610-X-5-.10 (2012) Functions And Activities
2Of Certified Registered Nurse Practitioners
. . . (3) ADVANCED PRACTICE NURSE. . . . A registered nurse. . . . Certified registered nurse
practitioners (CRNP). . . . Certified registered nurse practitioners . . . are subject to collaborative
practice agreements with an Alabama physician. . . . . (5) COLLABORATION. A formal
relationship between one or more certified registered nurse practitioners . . . and a physician or
physicians under which these nurses may engage in advanced practice nursing as evidenced by
written protocols approved in accordance with the requirements of this article or exempted in
accordance with requirements of this article. . . . Code of Ala. § 34-21-81 (2012) Definitions
Registered Nurses
Registered nurses (RNs) may assess patients in all states except Kentucky, Michigan, and
Pennsylvania (48/51). These states permit RNs to assess under their own authority. Twentythree of the 48 states also permit RNs to assess under delegated authority (Alabama, Arizona,
Delaware, DC, Florida, Hawai’i, Idaho, Illinois, Indiana, Kansas, Montana, Nebraska, New
Hampshire, New Mexico, North Dakota, Oklahoma, Oregon, South Carolina, Texas, Utah,
Vermont, Washington, and Wyoming).
No state prohibits RNs from conducting assessments.
Provisions from Illinois are below:
20
A registered professional nurse provides . . . nursing care . . . that includes but is not limited to: (1)
the assessment of healthcare needs, nursing diagnosis, planning, implementation, and nursing
evaluation . . . 225 Ill. Compiled Stat. 65/50-10 (2012) Definitions
(a) Practice as a registered professional nurse . . . includes, but is not limited to, all of the
following: (1) The comprehensive nursing assessment of the health status of patients that
addresses changes to patient conditions. . . 225 Ill. Compiled Stat. 65/60-35 (2012) RN scope of
practice
Practical and Vocational Nurses
Twenty-six states address how practical nurses (PNs) may assess patient status.
Massachusetts and North Carolina are the 2 states that permit PNs to assess independently.
Twenty-two states permit the practice under delegated authority. Arkansas and Iowa prohibit
PNs from conducting any assessments. Texas is the only state that permits vocational nurses
(VNs) to conduct assessments, but only under delegated authority.
The provision from Alabama defines delegated patient assessment duties for practical
nurses:
(1) Patient assessment shall be provided in accordance with the definitions of professional nursing
and practical nursing. . . . (3) The licensed practical nurse shall conduct and document focused
nursing assessments of the health status of patients by: (a) Collecting objective and subjective
data from observations, nursing examinations, interviews and written records in an accurate and
timely manner as appropriate to the patient's health care needs. (b) Distinguishing abnormal from
normal data. (c) Recording, and reporting the data. (d) Anticipating and recognizing changes or
potential changes in patient status; identifying signs and symptoms of deviation from current
health status. (e) Reporting findings of the focused nursing assessment to the registered nurse,
licensed physician, advanced practice nurse, or dentist. (f) Implementing the plan of care. Ala.
Admin. Code r. 610-X-6-.09 (2012) Assessment Standards
Authority to Prescribe Vaccines
Nurses in Advanced Practice
Every jurisdiction (except Arkansas, Michigan, and New Mexico), has authorized at least
one category of nurse in advanced practice to prescribe medications, either under their own
license or through delegated authority. Two states prohibit nurses in advanced practice from
prescribing: Alabama bars clinical nurse specialists from prescribing drugs, while Minnesota
disallows traditional midwives from prescription authority.
The following excerpts from Alabama show that registered nurse practitioners who
practice collaboratively are permitted prescriptive authority. However, clinical nurse specialists
who do not engage in collaborative practice may not prescribe drugs of any type:
(1) Certified registered nurse practitioners engaged in collaborative practice with physicians may
be granted prescriptive authority . . . . (2) Certified registered nurse practitioners practicing under
protocols . . . may prescribe legend drugs to their patients. . . . Ala. Admin. Code r. 610-X-5-.11
(2012) Prescriptions And Medication Orders By Certified Registered Nurse Practitioners
21
Certified registered nurse practitioners . . . engaged in collaborative practice with physicians
practicing under protocols approved in the manner prescribed by this article may prescribe legend
drugs to their patients. . . . Code of Ala. § 34-21-86 (2012) Prescribing legend drugs; initiating
call-in prescriptions; administering legend drug
(3) ADVANCED PRACTICE NURSE. A registered nurse. . . . [C]linical nurse specialists
(CNS). . . . [C]linical nurse specialists are not subject to collaborative practice agreements with an
Alabama physician . . . and are prohibited from engaging in any of the acts or functions of a
certified registered nurse practitioner (CRNP) or a certified nurse midwife (CNM). . . . (4) . . . d. . .
. [A] clinical nurse specialist may not. . . 3. Prescribe drugs of any type. . . . Code of Ala. § 34-2181 (2012) Definitions
Registered Nurses
Six states address how RNs may prescribe drugs, medications, or vaccines (Alaska,
Florida, Minnesota, Missouri, Oregon, and Tennessee). Forty-five states do not address
prescription authority. No state permits RNs to prescribe medications under their own license.
Under delegated authority, RNs may prescribe in Florida, Minnesota, Oregon, and Texas.
Alaska and Missouri prohibit RNs from prescribing medications. Minnesota’s law is below:
Subd. 8. Prescription by protocol. A registered nurse may implement a protocol that does not
reference a specific patient and results in a prescription of a legend drug that has been
predetermined and delegated by a licensed practitioner . . . when caring for a patient whose
condition falls within the protocol and when the protocol specifies the circumstances under which
the drug is to be prescribed or administered.
Subd. 9. Vaccine by protocol. A nurse may implement a protocol that does not reference a
specific patient and results in the administration of a vaccine that has been predetermined and
delegated by a licensed practitioner . . . when caring for a patient whose characteristics fall within
the protocol and when the protocol specifies the contraindications for implementation, including
patients or populations of patients for whom the vaccine must not be administered and the
conditions under which the vaccine must not be administered. . . . Minn. Stat. § 148.235 (2012)
Prescribing drugs and therapeutic devices
Practical and Vocational Nurses
Texas is the only state that addresses prescription authority for LPNs and VNs. No state
permits either category of nurse to prescribe drugs under their own authority or delegated
authority. Texas expressly indicates that VNs may not prescribe “therapeutic or corrective
measures,” as shown below:
. . . (5) “Vocational nursing” . . . does not include acts of medical diagnosis or the prescription of
therapeutic or corrective measures. Vocational nursing involves: (A) collecting data and
performing focused nursing assessments of the health status of an individual. . . . Tex. Stat. &
Codes § 301.002 (2012) Definitions
22
Authority to Administer Vaccines
Nurses in Advanced Practice
All states except Rhode Island address whether nurses in advanced practice may
administer medications. Twenty-two states permit at least one category of nurse in advanced
practice to administer medications independently and 46 states allow administration through
delegated authority. Minnesota is the only state that prohibits advanced practice nurses from
administering prescription drugs. Examples of independent administration authority from
Kentucky and New Hampshire are below:
(8) “Advanced registered nursing practice” means . . . registered nurses for advanced practice
registered nursing as a certified nurse practitioner . . . certified nurse midwife, or clinical nurse
specialist . . . . . . acts shall . . . include but not be limited to prescribing treatment, drugs . . . .
Advanced registered nurse practitioners . . . shall be authorized to issue prescriptions for and
dispense nonscheduled legend drugs. . . . . Ky. Rev. Stat. § 314.011 (2012) Definitions for
chapter
(7) “Healthcare provider” means a person licensed . . . to engage in advanced practice registered
nursing. . . . (8)(a) A healthcare provider [may] administer[] immunizations. . . . 902 Ky. Admin.
Regs. 2:060 (2012) Immunization schedules for attending child day care centers, certified
family child care homes, other licensed facilities which care for children, preschool programs,
and public and private primary and secondary schools
***
I. Advanced registered nursing practice by nurse practitioners . . . scope of practice . . . shall be
limited to:
(a) Performing acts of advanced assessment, diagnosing, prescribing, selecting,
administering, and providing therapeutic measures and treatment regimes . . . III. An ARNP shall
have plenary authority to . . . prescribe, administer, and dispense and distribute to clients . . . noncontrolled drugs within the scope of the APRN’s practice as defined by this chapter. . . . N.H.
Rev. Stat. § 326-B:11 (2012) Scope of Practice and Authority; Advanced Practice Registered
Nurse
Registered Nurses
Every state except North Carolina, Rhode Island, and Vermont governs how RNs may
administer medications. Eight states authorize RNs to administer medications under their own
authority (California, Connecticut, Iowa, Maryland, New Hampshire, New Jersey, Oregon, and
South Dakota). Forty-three states permit RNs to administer medications under delegated
authority. No state prohibits medication administration by RNs.
The following selections illustrate different approaches to medication administration for
RNs. New Jersey describes independent practice during periods of vaccine shortage. Oregon
illustrates how RNs may practice independently as a matter of routine practice, and Illinois
demonstrates administration under delegation:
b. To protect the public health during a vaccine shortage, the commissioner shall issue an order to
implement a New Jersey Vaccine Education and Prioritization Plan, which shall comprise . . . (2)
procedures for the distribution and administration of vaccines that shall apply to . . . nurses, health
care facilities, pharmacies and others that dispense vaccines. The procedures shall include, but not
be limited to, a definition of high-risk groups for priority protection or treatment in the event a
23
vaccine shortage is imminent or existent . . . . N.J. Stat. 26:13-23 (2012) New Jersey Vaccine
Education and Prioritization Plan; conditions for establishment; “vaccine” defined; penalties
for violation
***
(2) . . . the Registered Nurse shall . . . (d) Implement the plan of care by: (A) Implementing
treatments and therapy, appropriate to the context of care . . . medication administration. . . . Or.
Admin. Rules 851-045-0060 (2012) Scope of Practice Standards for Registered Nurses
***
A registered professional nurse provides . . . nursing care . . . that includes but is not limited to: . .
. (4) the administration of medications and treatments as prescribed by a physician licensed to
practice medicine . . . a licensed dentist, a licensed podiatrist, or a licensed optometrist or as
prescribed by a physician assistant . . . or by an advanced practice nurse. . . . 225 Ill. Compiled
Stat. 65/50-10 (2012) Definitions
(a) Practice as a registered professional nurse . . . includes, but is not limited to, all of the
following: . . . (3) The administration of medication or delegation of medication administration to
licensed practical nurses. . . . 225 Ill. Compiled Stat. 65/60-35 (2012) RN scope of practice
. . . registered nurse . . . will be responsible for administration of the remaining required
immunizations. . . . 105 Ill. Compiled Stat. 5/27-8.1 (2012) Health examinations and
immunizations
Practical and Vocational Nurses
Thirty-four states indicate the circumstances under which PNs and VNs may administer
medications. Of these 34 states, only California, Colorado, Michigan, and Texas address VNs.
Connecticut is the only state that allows PNs to administer medications as part of
independent practice, but only in limited situations. Twenty-eight states permit PNs to engage in
administration activities under delegation, as demonstrated by the example from Alabama.
Arkansas and Iowa are the 2 states that prohibit PNs from administering medications. Arkansas’
provision is related to providers who may administer vaccines to children enrolled in Medicaid,
while Iowa’s law ensures that PNs do not engage in practices reserved for RNs. Provisions from
Connecticut, Alabama, Arkansas, and Iowa are below:
[A] nurse who is employed by an agency licensed by the Department of Public Health as a home
health care agency or a homemaker-home health aide agency may administer influenza and
pneumococcal polysaccharide vaccines to persons in their homes . . . without a physician's order . .
. . For purposes of this section, “nurse” means [a] . . . practical nurse . . . . Conn. Gen. Stat. §
19a-492d (2012) Vaccinations and medication administered by nurses employed by home health
care agencies or homemaker-home health aide agencies
***
(a) . . . (c) . . . [L]icensed practical nurses are authorized to administer any legend drug that has
been lawfully ordered or prescribed by an authorized practitioner including certified registered
nurse practitioners, certified nurse midwives, and/or assistants to physicians. Code of Ala. § 3421-86 (2012) Prescribing legend drugs; initiating call-in prescriptions; administering legend
drugs
24
(3) . . . b. Practice of Practical Nursing. The performance, for compensation, of acts designed to
promote and maintain health, prevent illness and injury and provide care utilizing standardized
procedures and the nursing process, including administering medications and treatments, under the
direction of a licensed professional nurse or a licensed or otherwise legally authorized physician or
dentist. . . . Code of Ala. § 34-21-1 (2012) Definitions
***
All screenings and immunizations must be performed by personnel meeting, at a minimum,
registered nurse status. Ark. Admin. Code § 016.06.18-201.000 (2012) Arkansas Medicaid
Participation Requirements for Child Health Services (EPSDT) Providers Except School-Based
Child Health Services Providers
***
6.3(3) The licensed practical nurse shall not perform any activity requiring the knowledge
and skill ascribed to the registered nurse, including . . . d. The initiation or administration
of medications requiring the knowledge or skill level currently ascribed to the registered
nurse. . . . Iowa Admin. Code 655-6.3(152) (2012) Minimum standards of practice for
licensed practical nurses
Four states address medication administration authority for VNs (California, Colorado,
Michigan, and Texas). All these states authorize VNs to administer medications under delegated
authority. No state permits VNs to administer medications independently, while no state
prohibits them from administering.
California specifically allows a VN to vaccinate all patients, including students. (This
provision is also presented under Physician Assistant) The excerpt from Colorado shows that
the state incorporates medication administration in the scope of practice for both practical and
vocational nurses:
(a) A licensed vocational nurse, acting under the direction of a physician may perform . . . (2)
immunization techniques, providing such administration is upon standing orders of a supervising
physician, or pursuant to written guidelines adopted by a hospital or medical group with whom the
supervising physician is associated. Cal. Business and Professions Code § 2860.7 (2012)
Performance of skin tests and immunizations; supervision and guidelines; qualifications
(a) . . . [T]he [governing board of a school district] may permit a licensed physician and surgeon,
or a health care practitioner listed in subdivision (b) who is acting under the direction of a
supervising physician and surgeon, to administer an immunizing agent to a pupil whose parent or
guardian has consented in writing to the administration of the immunizing agent.
(b)(1) The following health care practitioners, acting under the direction of a supervising physician
and surgeon, may administer an immunizing agent within the course of a school immunization
program . . . (D) A licensed vocational nurse. . . .
(2) A health care practitioner's authority to administer an immunizing agent pursuant to this
subdivision is subject to the following conditions: (A) The administration of an immunizing agent
is upon the standing orders of a supervising physician and surgeon and in accordance with any
written regulations that the State Department of Public Health may adopt.
(B) The school nurse is notified and he or she maintains control, as necessary, as supervisor of
health . . . .
(C) The health care practitioner may only administer immunizations for the prevention and control
of any of the following: (i) Annual seasonal influenza. (ii) Influenza pandemic episodes. (iii)
25
Other diseases that represent a current or potential outbreak as declared by a federal, state, or local
public health officer. Cal. Education Code § 49403 (2012) Cooperation in control of
communicable disease and immunization of pupils
***
(8) “Practical nurse”, “trained practical nurse”, “licensed vocational nurse”, or “licensed practical
nurse” means a person . . . with the right to use the title “licensed practical nurse” . . . . (9)(a)
“Practice of practical nursing” means the performance, under the supervision of a dentist,
physician, podiatrist, or professional nurse authorized to practice in this state, of those services
requiring the education, training, and experience, as evidenced by knowledge, abilities, and skills
required in this article for licensing as a practical nurse . . . in . . . (IV) Administering treatments
and medications prescribed by: (A) A legally authorized dentist, podiatrist, or physician; or (B)
Physician assistant implementing a medical plan pursuant to . . . this section. (b) “Practice of
practical nursing” includes the performance of delegated medical functions. nel. Colo. Rev. Stat.
§ 12-38-103 (2012) Definitions
Defining Patients who may Receive Vaccinations
Georgia is the only state that identifies the age range of patients who may receive
vaccinations from RNs. RNs may administer influenza vaccine to children under age 13 with an
individual prescription from a physician. When the child is under age 18, only parental/guardian
consent is required.
Level of Supervision Required to Practice
Nurses in Advanced Practice
All states require nurses in advanced practice to collaborate with a licensed physician,
dentist, podiatrist, or licensed state health care delivery system to cooperate, coordinate, and
consult with each other as appropriate within a collaborative agreement. The examples from
Illinois show how the state approaches collaboration and physician liability:
For a physician and an APN to collaborate, both the Medical Practice Act and the Nurse Practice
Act require a written collaborative agreement for all APNs engaged in clinical practice. The
collaborative agreement must describe the working relationship of the APN with the collaborating
physician and authorize categories of care, treatment, or procedures to be performed by the APN.
An APN's scope of practice expressly includes (but is not limited to) “[prescriptive authority[.]”
A collaborating physician may delegate this authority pursuant to a written collaborative
agreement. This authority includes “prescription of, selection of, orders for, administration of,
storage of, acceptance of samples of, and dispensing over the counter medications, legend drugs . .
. and other preparations[.]” As with PAs, APNs may dispense or prescribe drugs or medical
supplies within the scope of practice of the supervising physician. 2009 WL 596125 Off. of the
Atty. Gen. State of Ill., File No. 09-002 (2012) Authority of Advanced Practice Clinicians to
Dispense and Administer Mifepristone (internal citations omitted)
(e) A physician shall not be liable for the acts or omissions of a[n] . . . advanced practice nurse
solely on the basis of having signed a supervision agreement or guidelines or a collaborative
agreement, an order, a standing medical order, a standing delegation order, or other order or
guideline authorizing a[n] . . . advanced practice nurse to perform acts, unless the physician has
reason to believe the . . . advanced practice nurse lacked the competency to perform the act or acts
or commits willful and wanton misconduct. (f) A collaborating physician may, but is not required
to, delegate prescriptive authority to an advanced practice nurse as part of a written collaborative
26
agreement, and the delegation of prescriptive authority shall conform to the requirements of
Section 65-40 of the Nurse Practice Act. . . . 225 Ill. Compiled Stat. 60/54.5 (2012) Physician
delegation of authority to physician assistants and advanced practice nurses
Registered Nurses
All RNs must practice in collaboration with licensed physicians, dentists, or podiatrists.
The laws from Georgia show how RNs must work with physicians in order to provide
comprehensive health services:
(8) “Practice nursing as a registered professional nurse” means to practice nursing by performing
for compensation any of the following . . . (G) Collaborating with other members of the health
care team in the management of care . . . (I) Administering, ordering, and dispensing medications,
diagnostic studies, and medical treatments authorized by protocol, when such acts are authorized
by other general laws and such acts are in conformity with those laws; (J) Administering
medications and treatments as prescribed by a physician . . . a dentist . . . or a podiatrist . . . (K)
Performing any other nursing act in the care and counsel of the ill, injured, or infirm, and in the
promotion and maintenance of health with individuals, groups, or both throughout the life span.
Code of Ga. § 43-26-3 (2012) Definitions
(a) . . . (7) “Nurse” means a registered professional nurse . . . . who is regularly employed by a
physician who actively engaged in the private practice of medicine. . . . (c) A physician engaged in
the active practice of medicine may prescribe influenza vaccine for a group of patients via an
influenza vaccine order contained in an influenza vaccine protocol agreement to be administered
by a nurse, provided the physician is registered with the vaccination registry . . . . (q) No influenza
vaccine protocol agreement entered into pursuant to this Code section shall permit a . . . nurse to
administer an influenza vaccine to any child under the age of 13 without an individual prescription
from a physician, and consent of the child's parent or legal guardian shall be a condition precedent
to the administration of an influenza vaccine to a child under the age of 18. Code of Ga. § 43-3426.1 (2012) Influenza vaccine protocol agreement; vaccination for groups of patients; rules and
regulations; liability
Practical Nurses
A supervising physician, dentist, podiatrist, nurse in advanced practice, registered nurse,
or physician assistant must provide practical nurses with direct, on-site supervision. The
selection from Georgia indicates LPNs may administer influenza vaccines under an established
protocol. In Illinois, LPNs may conduct patient assessments as directed by the supervising
provider authorized to delegate the activity:
(a) . . . (7) “Nurse” means . . . a licensed practical nurse . . . who is regularly employed by a
physician who actively engaged in the private practice of medicine. . . . (f) . . . a registered
professional nurse who is a party to an influenza protocol agreement pursuant to this Code section
may delegate the administration of influenza vaccine to a licensed practical nurse under the direct
on-site supervision of the registered professional nurse. . . . (q) No influenza vaccine protocol
agreement entered into pursuant to this Code section shall permit a . . . nurse to administer an
influenza vaccine to any child under the age of 13 without an individual prescription from a
physician, and consent of the child's parent or legal guardian shall be a condition precedent to the
administration of an influenza vaccine to a child under the age of 18. Code of Ga. § 43-34-26.1
(2012) Influenza vaccine protocol agreement; vaccination for groups of patients; rules and
regulations; liability
27
***
(a) Practice as a licensed practical nurse means a scope of basic nursing practice . . . as delegated
by a registered professional nurse or an advanced practice nurse or as directed by a physician
assistant, physician, dentist, or podiatrist, and includes, but is not limited to, all of the following:
(1) Collecting data and collaborating in the assessment of the health status of a patient. . . . 225 Ill.
Compiled Stat. 65/55-30 (2012) LPN scope of practice
Settings where Nurses are Authorized to Vaccinate
In addition to public and private clinical settings, nurses may practice in a broad range of
locations, including: any and all settings, a patient’s home, a hospice, home health agency,
community health settings, school nursing, occupational nursing, correctional facilities, and
community mental health facilities.
28
Table 4: STANDING ORDERS: Nurses with Advanced Practices & Immunization Practice
STATE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Mass.
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
N Hamp.
N Jersey
N Mexico
N York
N Carolina
N Dakota
Ohio
Oklahoma
Oregon
Penn.
R Island
S Carolina
S Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
W Virginia
Wisconsin
Wyoming
Own
Authority
A, C,N
C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
ASSESSMENT
Delegated
Authority
A,C,N
A,C,N
A, N
A, C, N
A,C,N
A,C,N
A, C, N
A,C,N
A,C,N
A,C,N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
C, N
A, C, N
A, N
A, C, N
A, C, N
A, C, N
A,C,N
A, C, N
A, C, N
A, N
C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
Prohibited
PRESCRIPTION
Independent Delegated
Prohibited
Authority
Authority
A, N
A, C
N
N
N
A, C, N
A, C, N
A, C, N
A
A, C, N
A, C, N
C, N
A,C,N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, N
A
A,N
A, N
A, C, N
A, N
A, C, N
A, C, N
A, N
A
A, C, N
A, N
A, C, N
N
A, N
A, N
A, C, N
C, N
N
A,C,N
N
A, C, N
A, C, N
A,C,N
A, N
A
N
A, N
A, C, N
A, C, N
A, C, N
C, N
N
A, C
C, N
A,C,N
A, C, N
N
A, N
A,C,N
A
A, N
N
A,C,N
A
A, N
A, C, N
A, N
A, C, N
A, C, N
A, C, N
A, C, N
A
A
ADMINISTRATION
Own
Delegated
Prohibited
Authority
Authority
A, C, N
N
C,N
N
A, C,N
A, C, N
A,C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A,C,N
A,C, N
A, C, N
A,C,N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A,C,N
A, C, N
A, N
A, C,N
A, C, N
A,C,N
A, N
A,C,N
A,C,N
A, C, N
A
A, C, N
A, C, N
A,C,N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, C, N
A, N
A, C, N
A, C, N
A, C, N
A, C, N
C, N
A, C, N
A, C, N
A
A
A, N
A, C, N
A= Advanced Practice, C=Clinical Nurse Specialist, N=Nurse Practitioner
Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice—Fall 2013
29
A, C, N
A,C,N
A, C, N
A, C, N
C, N
A
C, N
A,C,N
A, C, N
A, C, N
A, C, N
Table 5: STANDING ORDERS: Practical and Vocational Nurses & Immunization Practice
STATE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Mass.
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
N Hamp.
N Jersey
N Mexico
N York
N Carolina
N Dakota
Ohio
Oklahoma
Oregon
Penn.
R Island
S Carolina
S Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
W Virginia
Wisconsin
Wyoming
Own
Authority
ASSESSMENT
Delegated
Authority
P
P
Prohibited
Own
Authority
PRESCRIPTION
Delegated
Prohibited
Authority
P
ADMINISTRATION
Delegated
Prohibited
Authority
P
P
P
P
P
P
P
P
P
Own
Authority
V
P,V
P
P
P
P
P
P
P
P
P
P
P
P
P
P,V
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P, V
P
P
V
P
P
P
P,V
P
P
P
P
P
P
P
P = Practical Nurse V= Vocational Nurse
Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice—Fall 2013
30
P
P
Table 6: STANDING ORDERS: Registered Nurses & Immunization Practice
STATE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Mass.
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
N Hamp.
N Jersey
N Mexico
N York
N Carolina
N Dakota
Ohio
Oklahoma
Oregon
Penn.
R Island
S Carolina
S Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
W Virginia
Wisconsin
Wyoming
Own
Authority
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
ASSESSMENT
Delegated
Authority
●
Prohibited
Own
Authority
PRESCRIPTION
Delegated
Prohibited
Authority
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
ADMINISTRATION
Own
Delegated
Prohibited
Authority
Authority
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice—Fall 2013
31
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Figure 3 – Vocational and Practical Nurses
Vocational and Licensed Practical Nurses are most frequently permitted to administer medications
followed by immunizations.
Immunizations or Vaccines
Arkansas (prohibited)
California
Illinois
Massachusetts
Michigan
Mississippi
Pennsylvania
Tennessee
Texas
Virginia
Drugs or Legend Drugs/Substances
Alabama
Kansas
Texas
Wisconsin
Medications
Alabama
Colorado
Delaware
Florida
Hawai’i
Idaho
Illinois
Iowa (prohibited)
Kentucky
Maine
Maryland
Minnesota
Mississippi
Montana
North Dakota
Ohio
Pennsylvania
South Carolina
South Dakota
Utah
Wyoming
Injectable Medication/Inoculation
Washington
Influenza
California
Connecticut
Georgia
Hepatitis B
Tennessee
Pneumococcal
Connecticut
32
Figure 4 – Registered Nurses
Registered Nurses are most frequently permitted to administer medications followed by
immunizations or vaccines.
Drugs or Legend Drugs/Substances
Alabama
Kansas
Kentucky
Massachusetts
Minnesota
Missouri
Texas
Wisconsin
Immunizations or Vaccines
Alaska
Arkansas
California
Illinois
Indiana
Iowa
Maine
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
New Hampshire
New Jersey
New Mexico
New York
Pennsylvania
Tennessee
Texas
Virginia
Medications
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Iowa
Kentucky
Maine
Maryland
Minnesota
Mississippi
Montana
Nevada
New Mexico
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Washington
West Virginia
Injectable Medication/Inoculation
Alaska
Washington
Prevention
Florida
Maryland
Virginia
Washington
Influenza
California
Connecticut
Georgia
New Hampshire
Hepatitis B
Tennessee
Pneumococcal
California
Connecticut
Wyoming
33
Figure 5 – Advanced Practice Nurses
Advanced Practice Nurses are most frequently permitted to administer medications followed by
immunizations or vaccines. Influenza vaccine is most frequently identified.
Drugs or Legend
Drugs/Substances
Alabama
Connecticut
Delaware
Hawai’i
Illinois
Indiana
Kansas
Kentucky
Louisiana
Maine
Massachusetts
Minnesota
Missouri
Montana
North Carolina
North Dakota
South Carolina
Texas
Utah
Washington
Wisconsin
Medications
Alabama
Arizona
Arkansas
California
Colorado
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Iowa
Kentucky
Maine
Maryland
Minnesota
Mississippi
Montana
Nevada
New Mexico
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Washington
West Virginia
Wyoming
New York
Pennsylvania
Tennessee
Texas
Washington
Immunizations or Vaccines
Arkansas
California
DC
Hawai’i
Illinois
Indiana
Iowa
Kentucky
Maine
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
New Hampshire
New Jersey
New Mexico
HBIG
Washington
34
Injectable
Medication/Inoculation
Washington
Pharmacological Agents
Hawai’i
Idaho
Influenza
California
Connecticut
Georgia
Massachusetts
New Hampshire
Hepatitis B
Tennessee
Washington
MMR
Washington
Pneumococcal
California
Connecticut
Rubella
Vermont
Figure 6 – Certified Nurse Specialists
Certified Nurse Specialists are most frequently permitted to administer medications followed
by immunizations and vaccines. Influenza vaccine is most frequently identified.
Drugs or Legend
Drugs/Substances
Alabama
Connecticut
Illinois
Kansas
Kentucky
Louisiana
Massachusetts
Minnesota
Missouri
Montana
North Dakota
South Carolina
Texas
Wisconsin
Medications
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Delaware
DC
Florida
Hawai’i
Idaho
Illinois
Iowa
Kentucky
Maine
Maryland
Minnesota
Mississippi
Montana
Nevada
New Mexico
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Washington
West Virginia
Wyoming
Immunizations or Vaccines
Alaska
Arkansas
California
Hawai’i
Illinois
Indiana
Iowa
Kentucky
Maine
Massachusetts
Michigan
35
Minnesota
Mississippi
Missouri
New Hampshire
New Jersey
New Mexico
New York
Pennsylvania
South Dakota
Tennessee
Texas
Virginia
Injectable
Medication/Inoculation
Alaska
Washington
Pharmacological Agents
Hawai’i
Idaho
Influenza
California
Connecticut
New Hampshire
Hepatitis B
Tennessee
Pneumococcal
California
Connecticut
Figure 7 – Nurse Practitioners
Nurse Practitioners are most frequently permitted to administer medications followed by
immunizations and vaccines. Influenza vaccine is most frequently identified.
.
Drugs or Legend
Drugs/Substances
Alabama
Alaska
Arizona
California
Connecticut
Hawai’i
Illinois
Kansas
Kentucky
Louisiana
Maine
Massachusetts
Minnesota
Missouri
Montana
New Hampshire
New York
North Carolina
North Dakota
Oregon
Pennsylvania
South Carolina
Texas
Wisconsin
Hawai’i
Idaho
Illinois
Iowa
Kentucky
Maine
Maryland
Minnesota
Mississippi
Montana
Nevada
New Mexico
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Washington
West Virginia
Wyoming
Medications
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Delaware
DC
Florida
Georgia
Immunizations or Vaccines
Alaska
Arkansas
California
Hawai’i
Illinois
Indiana
Iowa
Kentucky
Maine
Massachusetts
36
Michigan
Minnesota
Mississippi
Missouri
New Hampshire
New Jersey
New Mexico
New York
Pennsylvania
South Dakota
Tennessee
Texas
Virginia
Washington
Injectable
Medication/Inoculation
Alaska
Washington
Pharmacological Agent
Hawai’i
Idaho
Influenza
California
Connecticut
Georgia
Massachusetts
New Hampshire
Hepatitis B
Tennessee
Pneumococcal
California
Connecticut
PHARMACISTS
All 51 states address whether pharmacists may assess patient status, prescribe drugs,
medications, or vaccines, or administer vaccines. See Table 7 and Figures 8 and 9 below.
Authority to Assess Patient Status
Five states address a pharmacist’s ability to assess patient status. Missouri and North
Carolina permit pharmacists to assess patients under the pharmacist’s own license. Maine, New
Jersey, and North Carolina allow assessments pursuant to delegated authority. No state prohibits
pharmacists from accessing patients.
The following excerpts from Maine and Missouri show the different approaches to
patient assessment. Missouri has developed an exception for influenza and pneumococcal
vaccination, permitting pharmacists to assess for contraindications in hospitals:
Prior to administering a[n] . . . immunization, a pharmacist who holds a certificate of
administration shall assess the patient for contraindications that would preclude vaccination. . . .
Code of Maine Rules 02-392 Ch. 4-A, § 2 (2012) Administration Requirements
***
PURPOSE: This rule establishes the requirements for pharmacy services and medication
management in a hospital. . . . 34) All medication orders shall be written in the medical record
and signed by the ordering practitioner with the exception of influenza and pneumococcal
polysaccharide vaccines, which may be administered per physician-approved hospital
policy/protocol after an assessment for contraindications. . . . 19 Mo. Code of State Regs. 3020.100 (2012) Pharmacy Services and Medication Management in Hospitals
Authority to Prescribe Vaccines
Nine state laws indicate whether pharmacists may prescribe medications. Idaho, Oregon,
and Wyoming are the 3 states permitting prescription authority under the pharmacist’s own
license. Six states allow pharmacists to prescribe medications under delegated authority
(Massachusetts, Mississippi, Montana, New Mexico, North Dakota, and Wyoming). South
Dakota is the only state that expressly prohibits pharmacists from prescribing drugs.
Provisions from Idaho permitting independent prescription authority, Mississippi allowing
prescribing in institutions, and South Dakota prohibiting prescription authority are below:
Licensed pharmacists may also prescribe agents for active immunization when prescribed for
susceptible persons twelve (12) years of age or older for the protection from communicable
disease. Idaho Code § 54-1704 (2012) Practice of pharmacy
***
(ll) “Written guideline or protocol” means an agreement in which any practitioner authorized to
prescribe drugs delegates to a pharmacist authority to conduct specific prescribing functions in an
institutional setting, or with individual patients, provided that a specific protocol agreement is
signed on each patient and is filed as required by law or by rule or regulation of the board. . . .
Miss. Code § 73-21-73 (2012) Definitions
37
***
The practice of pharmacy does not authorize a pharmacist to prescribe drugs as a practitioner.
S.D. Codified Laws § 36-11-22 (2012) Practice of pharmacy defined
Authority to Administer Vaccines
All 51 states address how pharmacists may administer medications.
Fourteen states have granted pharmacists the power to administer vaccines and/or drugs
as part of their independent practice (Alabama, Arizona, Idaho, Maine, Mississippi, Nebraska,
New Hampshire, Oregon, South Carolina, South Dakota, Tennessee, Washington, West Virginia,
and Wyoming).
Forty-two states permit pharmacists to administer vaccines under delegated authority
(Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia,
Florida, Georgia, Hawai’i, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine,
Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire,
New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma,
Pennsylvania, Rhode Island, South Dakota, Texas, Utah, Vermont, Virginia, Wisconsin, and
Wyoming).
The excerpt from Maine is an example of pharmacists’ ability to administer vaccines
without a prescription or standing order. The selections below from Wyoming show that
pharmacists may administer vaccines “only by prescription” in certain circumstances, and under
their own authority only to healthy adults:
[NOTE: A prescription, treatment protocol or written standing order from an authorized
practitioner is not required for administration of influenza vaccines.] . . . Code of Maine Rules
02-392 Ch. 4-A, § 1 (2012) Minimum Requirements for Treatment Protocol Issued Pursuant to
32 MRSA §13833
***
(a) A pharmacist licensed under this act may only prescribe and administer immunizations
recommended for healthy adults as authorized by the board. (b) A pharmacist licensed under this
act may administer immunizations to adults who are considered high risk only by prescription
from a licensed physician. . . . Wyo. Stat. § 33-24-157 (2012) Immunization administration
(a) A pharmacist licensed by the board may prescribe and administer immunizations to healthy
adults or administer immunizations to High- Risk Adults authorized by a physician, provided the
pharmacist has: (i) Registered with the board to prescribe and administer immunizations. . . .
Wyo. Rules & Regs. Ch. 16, Sec. 3 (2012) Qualifications
Defining Patients who may Receive Vaccinations
Forty-one states identify the ages of patients who may receive vaccines from pharmacists.
Ten states have not addressed patient age (Alabama, Alaska, Michigan, Mississippi, Nebraska,
Nevada, Oklahoma, Tennessee, Utah, and Washington). See Figure A
38
Twenty-four states permit pharmacists to vaccinate children (Arizona, Arkansas,
Colorado, Georgia, Hawai’i, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine,
Maryland, Minnesota, Missouri, Montana, New Hampshire, New Mexico, North Dakota, Ohio,
Oregon, Rhode Island, Texas, and Wisconsin). Of these 24 states, Colorado and Georgia restrict
administration only to children.
Children are defined by several age ranges, including: Children, under 13, 9-13, 14 and
older, 6-17, 14-17, or under 18. The quotes from Wisconsin appear be inconsistent regarding the
appropriate patient age ranges:
(2) . . . A pharmacist may not administer a vaccine under this subsection to a person who is under
the age of 6.
(2g) . . . . A person engaged in the practice of pharmacy . . . may not administer a vaccine under
this subsection to a person who is under the age of 18. . . . Wis. Stat. 450.035 (2012)
Administration of drug products and devices; vaccines
Thirty-nine states permit pharmacists to vaccinate adults who are variously defined as 18
and over, adults, the general public, any age, 19 and over, or any person. The states are Arizona,
Arkansas, California, Connecticut, Delaware, DC, Florida, Hawai’i, Idaho, Illinois, Indiana,
Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Missouri,
Montana, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota,
Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Vermont,
Virginia, West Virginia, Wisconsin, and Wyoming.
Seventeen of these states restrict vaccination to adults (California, Connecticut,
Delaware, DC, Florida, Iowa, Massachusetts, New Jersey, New York, North Carolina,
Pennsylvania, South Carolina, South Dakota, Vermont, Virginia, West Virginia, and Wyoming).
Level of Supervision Required to Practice
Fourteen states allow pharmacists to administer vaccines as a component of their
independent practice (Alabama, Arizona, Idaho, Maine, Mississippi, Nebraska, New Hampshire,
Oregon, South Carolina, South Dakota, Tennessee, Washington, West Virginia, and Wyoming).
The provisions below show that Arizona authorizes pharmacists to administer vaccines to
adults without a prescription, or under delegated authority based on the patient’s age, during a
public health emergency, or the specific vaccine to be administered. Idaho authorizes
pharmacists to prescribe and administer vaccines to individuals ages 12 and older:
A. . . . [A] pharmacist . . . may administer the following to adults without a prescription. . . 1.
Immunizations or vaccines listed in the United States centers for disease control and prevention's
recommended adult immunization schedule. 2. Immunizations or vaccines recommended by the
United States centers for disease control and prevention's health information for international
travel.
B. A pharmacist . . . may administer the following to a person who is at least six years of age but
under eighteen years of age without a prescription . . . 1. Immunizations or vaccines for influenza.
2. Immunizations or vaccines in response to a public health emergency declared by the governor. .
39
C. Pursuant to a prescription order, a pharmacist . . . may administer immunizations and vaccines
to a person who is at least six years of age but under eighteen years of age. . . . Ariz. Rev. Stat. §
32-1974 (2012) Pharmacists; administration of immunizations, vaccines and emergency
medications; certification; reporting requirements; advisory committee; definition; see also
Ariz. Admin. Code § R4-23-411 (2012) Pharmacist-administered or Pharmacy or Graduate
Intern-administered Immunizations (for similar language)
A. . . . 1. “Certified pharmacist” means an individual . . . who is authorized . . . to administer
immunizations or vaccines to adults. . . . B. The following immunizations or vaccines require a
prescription order before the immunization or vaccine may be administered . . . by a certified
pharmacist: 1. Japanese Encephalitis vaccine, 2. Rabies vaccine, 3. Typhoid vaccines, and 4.
Yellow fever vaccine. Ariz. Admin. Code § R9-6-1301 (2012) Immunizations or Vaccines
Requiring a Prescription Order for Pharmacist Administration
***
“Practice of pharmacy” means . . . drug administration . . . . Licensed pharmacists may also
prescribe agents for active immunization when prescribed for susceptible persons twelve (12)
years of age or older for the protection from communicable disease. Idaho Code § 54-1704
(2012) Practice of pharmacy
Forty-two states permit pharmacists to administer vaccines under delegated authority
(Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia,
Florida, Georgia, Hawai’i, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine,
Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire,
New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma,
Pennsylvania, Rhode Island, South Dakota, Texas, Utah, Vermont, Virginia, Wisconsin, and
Wyoming).
Examples from Arkansas and Colorado are below. Arkansas has created an exception to
their rule that prescriptions issued by an authorized practitioner are required before a pharmacist
may administer drugs and medicines. Influenza vaccines may be administered under a general
written protocol based on the age of the patient. Other vaccines require additional supervision.
Colorado requires a physician to authorize any vaccination and to also provide a protocol
outlining how to respond to adverse reactions, identifies the educational materials to be
distributed to patients, and highlights reporting requirements:
(16)(A) “Practice of pharmacy” means the learned profession of: (i)(a) Dispensing, selling,
distributing, transferring possession of, vending, bartering, or, in accordance with regulations
adopted by the Arkansas State Board of Pharmacy, administering drugs, medicines, poisons, or
chemicals that under the laws of the United States or the State of Arkansas may be sold or
dispensed only on the prescription and order of a practitioner authorized by law to prescribe drugs,
medicines, poisons, or chemicals.
(b) Except in accordance with regulations adopted by the Arkansas State Board of Pharmacy as
recommended by the Medications Administration Advisory Committee, the administration of
medications shall be limited to the following classifications of medications: immunizations,
vaccines. . . .
(c) Influenza vaccines and influenza immunizations may be administered to a person seven (7)
years of age and older under a general written protocol.
(d) Vaccines and immunizations other than influenza vaccines and influenza immunizations may
40
be administered to a person from seven (7) years of age to eighteen (18) years of age under a
patient-specific order or prescription and subject to reporting of the administration to the
prescribing physician together with any reporting required under § 20-15-1203.
(e) Vaccines and immunizations other than influenza vaccines and influenza immunizations may
be administered to a person eighteen (18) years of age or older under a general written protocol. . .
.
(g) A general written protocol . . . and patient-specific orders or prescriptions . . . shall be from a
physician licensed by the Arkansas State Medical Board and practicing in Arkansas or within fifty
(50) miles of the Arkansas border. . . . Ark. Code § 17-92-101 (2012) Definitions
. . . (b) Authority to administer medications/immunizations:
(1) An Authority to Administer is a written protocol . . . from a practitioner for administration by a
pharmacist of an approved medication or immunization.
(2) Pharmacists may provide pharmaceutical care to patients seven (7) years of age and older by
administering medications or immunizations to an eligible patient upon receiving an Authority to
Administer or a valid prescription order by a practitioner so authorized to prescribe such
medications or immunizations. . . . After completing the course of study . . . licensed interns . . .
may provide pharmaceutical care to patients seven (7) years of age and older by administering
medications or immunizations to an eligible patient, under the supervision of an appropriately
licensed pharmacist with an Authority to Administer. . . . (c) Seven classifications of approved
medications for administration (1) Immunizations (2) Vaccines. . . . . Ark. Admin. Code §
070.00.9-09-00-0002 (2012) Prescription Orders to Administer Medication and/or
Immunizations
***
19.01.10 Qualifications. a. A pharmacist, or pharmacy intern under the supervision of a
pharmacist certified in immunization, may administer vaccines AND IMMUNIZATIONS per
authorization of a physician. . . . Routine childhood immunizations, as defined by the Colorado
State Board of Health, shall comply with CDC guidelines. . . 19.01.20 A trained pharmacist may
delegate the administration of vaccines AND IMMUNIZATIONS only to a trained pharmacy
intern. 19.01.30 Policies and Procedures . . . b. . . . The prescription drug outlet must obtain a
physician protocol for addressing allergic reactions to immunizations. c. The prescription drug
outlet must give the appropriate "Vaccine Information Statement" (VIS) to the patient or legal
representative with each dose of vaccine covered by these forms. The pharmacist must ensure that
the patient or legal representative has received and signed the informed consent form and has had
their questions answered prior to the administration of the vaccine. d. The prescription drug outlet
must report adverse events as required by the Vaccine Adverse Events Reporting System
(VAERS) and to the primary care provider as identified by the patient. . . 3 Colo. Code. Regs.
719-1:19.00.00 (2012) Administration
41
Settings where Pharmacists are Authorized to Vaccinate
Fifteen states identify the settings where pharmacists may or may not practice
(California, Colorado, District of Columbia, Indiana, Massachusetts, Mississippi, Missouri,
Nevada, New Hampshire, New Mexico, North Dakota, Oklahoma, Pennsylvania, Texas, and
Utah).
In addition to pharmacies, hospitals, and other health care facilities, Colorado permits
pharmacists to “remove . . . vaccines from the prescription drug outlet . . . for off-site
administration.” In the District of Columbia, “the locations . . . . shall not include where a
patient resides, except for a licensed nursing home, residential care facility assisted living center,
the District of Columbia jail or a hospital.” However, in Indiana, administration can occur in a
hospice or a patient’s home and in a home health agency. Texas authorizes administration in
“any other location specifically identified in the written protocol.”
42
Table 7: STANDING ORDERS: Pharmacists & Immunization Practice
STATE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Mass.
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
N Hamp.
N Jersey
N Mexico
N York
N Carolina
N Dakota
Ohio
Oklahoma
Oregon
Penn.
R Island
S Carolina
S Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
W Virginia
Wisconsin
Wyoming
ASSESSMENT
Own
Delegated
Authority
Authority
Prohibited
Own
Authority
PRESCRIPTION
Delegated
Prohibited
Authority
Own
Authority
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
ADMINISTRATION
Delegated
Prohibited
Authority
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice—Fall 2013
43
Figure 8 - Pharmacists
Vaccines Pharmacists are Authorized to Administer
Influenza vaccine is most frequently highlighted, followed by Pneumococcal and Zoster vaccines.
Drugs
Alabama
Alaska
Mississippi
Nebraska
Tennessee
Utah
Vaccines, Immunizations
Arizona
Arkansas
Colorado
Delaware
Hawai’i
Idaho
Illinois
Iowa
Kansas
Kentucky
Louisiana
Maryland
Massachusetts
Michigan
Minnesota
Montana
Nevada
New Jersey
New Mexico
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
Texas
Vermont
Virginia
Washington
Wisconsin
Diphtheria
Ohio
Hepatitis A
Ohio
West Virginia
Wyoming
Hepatitis B
Ohio
West Virginia
Wyoming
HPV
Wyoming
Influenza
Arizona
Arkansas
California
Connecticut
DC
Florida
Georgia
Hawai’i
Indiana
Iowa
Kansas
Kentucky
Maine
Maryland
Massachusetts
Minnesota
Missouri
Montana
New Hampshire
New York
North Carolina
North Dakota
Ohio
Rhode Island
South Carolina
South Dakota
Texas
West Virginia
Wyoming
Japanese Encephalitis
Arizona
Meningococcal
Missouri
Ohio
Wyoming
Missouri
New Hampshire
New York
North Carolina
Ohio
West Virginia
Wyoming
Pertussis
Ohio
Rabies
Arizona
Tetanus
Ohio
West Virginia
Tetanus-diphtheria
Maine
West Virginia
Wyoming
Tdap
West Virginia
Wyoming
Booster Tetanus-diphtheria
Maine
Typhoid
Arizona
Varicella
Wyoming
Yellow Fever
Arizona
Zoster
Connecticut
Florida
Indiana
Maine
Maryland
Missouri
New Hampshire
North Carolina
Ohio
West Virginia
Wyoming
MMR
Wyoming
Pneumococcal
California
Connecticut
DC
Florida
Iowa
Maine
Maryland
44
FIGURE 9: PERMISSIBLE POPULATIONS FOR PHARMACIST-ADMINISTERED IMMUNIZATIONS
PATIENT
STATE
DEFINITION
SPECIAL INSTRUCTIONS
AGE
Alabama
Alaska
N/A
N/A
N/A
Drug
Arizona
Adults
Recommended by
CDC & for travel
Japanese
Encephalitis Rabies
Typhoid
Yellow fever
Medicaid will reimburse for vaccine administration
Written protocol must be approved by a practitioner authorized to prescribe drugs and
approved by the board
Without a prescription or Immunizations in response to a public health emergency
declared by the governor
6-17
Influenza
Pursuant to a prescription order
6-17
7+
Vaccines
Influenza
Pursuant to a prescription order
General written protocol.
7-17
Other than influenza
Patient-specific order or prescription and subject to reporting of the administration to
the prescribing physician together with any other reporting requirements
California
18+
50+
Colorado
Children
A general written protocol
Pursuant to standing orders in a skilled nursing facility and approval of facility medical
director
Pursuant to physician authorization
Connecticut
Adult
Delaware
DC
Adult
18+ with valid ID
Any
Influenza
Pneumococcal
Routine childhood
immunizations, as
defined by the
Colorado State
Board of Health and
the CDC
Flu
Pneumococcal
Zoster
Immunizations
Pneumococcal
Influenza
Arkansas
Pursuant to the order of a licensed health care provider
Pursuant to a valid prescription or physician protocol
Pursuant to a written protocol signed and dated by a licensed physician
Other Permissible Patients
Current patients or patients who have received care from the physician within the
twelve months prior to the date of the written protocol;
Current patients of a practice's care or patients who have received care within the
practice within the twelve months prior to the date of the written protocol;
Residents of a health care, residential services, or assisted living facility, when the
facility’s medical director is making the delegation;
DC residents identified by the Director of the Department of Health as part of a public
health services program, when the Director is the physician making the delegation
Florida
Adult
Influenza
Pneumococcal
Zoster
DC jail inmates, when the medical director is making the delegation
Established protocol
45
FIGURE 9: PERMISSIBLE POPULATIONS FOR PHARMACIST-ADMINISTERED IMMUNIZATIONS
PATIENT
STATE
DEFINITION
SPECIAL INSTRUCTIONS
AGE
Georgia
Under 13
Influenza
Individual prescription from a physician
Hawai’i
Under 18
14-17
Influenza
Influenza
Consent of parent or legal guardian
Pursuant to a valid prescription
Idaho
18+
12+
N/A
May prescribe
Illinois
Indiana
14+
18+
Vaccines
For protection from
communicable
disease
Vaccinations
Influenza
Zoster
14-17
Iowa
Adults
Influenza
Pneumococcal
Pursuant to a valid prescription or standing order, by a licensed physician
Pursuant to a drug order, prescription, or a protocol approved by a physician
Pursuant to a protocol only if the pharmacist receives the consent of a parent or legal
guardian, and the parent or legal guardian is present at the time of immunization
Pursuant to a written protocol for one or more patients
Kansas
6-17
Other adult
vaccines
Influenza
Kentucky
18+
Child
Other than influenza
Immunizations
Pursuant to a vaccination protocol
Pursuant to protocols
9-13
Influenza
Pursuant to prescriber-approved protocols with the consent of a parent or guardian
14-17
Immunizations
Pursuant to prescriber-approved protocols with the consent of a parent or guardian;
Louisiana
Adults
Under 14
Immunizations
Vaccines
Pursuant to prescriber-approved protocols
Pursuant to a prescription and informing the practitioner within 24 hours of the
administration if the patient is under 14 years old
Maine
16+
9+
Vaccines
Influenza
Collaborative drug therapy management agreement including a patient specific order
Pursuant to a treatment protocol authorizing the administration of immunizations and
a prescription, treatment protocol or standing order.
Under age 18
Pneumococcal
Zoster
Tetanus-diphtheriapertussis
Tetanus-diphtheria
Booster tetanusdiphtheria
Pursuant to a prescription
18+
Pneumococcal
Zoster
Tetanus-diphtheriapertussis
Tetanus-diphtheria
Booster tetanusdiphtheria
Pursuant to a treatment protocol or standing written order, the pharmacist shall verify
that the patient is 18 years of age or older.
Pursuant to a physician prescription or medication order for an individual patient
Pursuant to a vaccination protocol
46
FIGURE 9: PERMISSIBLE POPULATIONS FOR PHARMACIST-ADMINISTERED IMMUNIZATIONS
PATIENT
STATE
DEFINITION
SPECIAL INSTRUCTIONS
AGE
Maryland
9-18
Influenza
In accordance with regulations adopted by the Board, in consultation with the
Department. Report to state’s Immunization Registry
Adult
Pursuant to a prescription from a physician
18+
Influenza
Pneumococcal
Zoster
Any other
Influenza
Michigan
Minnesota
N/A
10+
Other
immunizations
Immunizing Agent
Influenza
Pursuant to the order of a physician and if the pharmacist is authorized to administer a
controlled substance
Administration under the direction of a physician
Pursuant to standing orders or a written protocol with a physician
Mississippi
Missouri
18+
N/A
12+
Pursuant to standing orders or a written protocol with a physician
Pursuant to specific protocol agreement signed for each patient
Pursuant to written protocol authorized by a physician
Montana
12+
All other vaccines
Drugs
Influenza
Pneumonia
Zoster
Meningitis
Influenza
18+
N/A
N/A
General Public
Vaccines
Drug
Immunizations
Influenza
Pursuant to collaborative practice agreement
N/A
Pursuant to a written protocol
Pursuant to collaborative pharmacy practice agreement
May also administer under individual pharmacist license
18+
Pursuant to collaborative pharmacy practice agreement
May also administer under individual pharmacist license
Pursuant to a standing order or prescription
Pursuant to written protocol
Mass
Nebraska
Nevada
New
Hampshire
Pursuant to a collaborative practice agreement
Pursuant to collaborative practice agreement
During a Public Health Emergency: State medical officer directive
New Jersey
New Mexico
18+
Any age
New York
18+
North
Carolina
18+
North Dakota
5+
Pneumococcal
Zoster
Vaccines
ACIP-recommended
or New Mexico
Department of
Health
Influenza
Pneumococcal
Influenza
Pneumococcal
Zoster
Influenza
Ohio
11+
14+
Vaccinations
Influenza
Upon order of a provider authorized to prescribe or by written protocol
Pursuant to a physician approved protocol
Pneumonia
Tetanus
Hepatitis A
Hepatitis B
Meningitis
Diphtheria
Pertussis
Zoster
Any other approved
Pursuant to a patient specific prescription
18+
Pursuant to patient specific and non-patient specific orders and protocols
Pursuant to a written protocol
Only in consultation with primary care provider (Pneumococcal, Zoster)
Upon order of a provider authorized to prescribe or by written protocol
47
FIGURE 9: PERMISSIBLE POPULATIONS FOR PHARMACIST-ADMINISTERED IMMUNIZATIONS
PATIENT
STATE
DEFINITION
SPECIAL INSTRUCTIONS
AGE
Oklahoma
Oregon
N/A
11-18
Immunizations
Vaccines
Penn
19+
18+
Immunizations
Rhode Island
9 through18
Influenza
The state will not reimburse providers the cost of privately purchased vaccination.
Pursuant to an order or written protocol approved by a physician or institutional
medical staff
Pursuant to a valid prescription or prescriber approved protocol
S Carolina
S Dakota
Tennessee
Texas
18+
18+
18+
N/A
0-13
Immunizations
Influenza
Influenza
Drugs
Immunizations
Pursuant to a valid prescription or physician approved protocol
Pursuant to a written protocol
Pursuant to authorization by the Board of Pharmacists or a prescription drug order.
None
Pursuant to physician supervision and referral
7+
Influenza
Pursuant to standing delegation orders
Utah
Vermont
Any age
N/A
18+
Immunizations
Prescription drug
CDC-recommended
Virginia
Washington
West Virginia
Adult
N/A
18+
Wisconsin
6+ or 18+
Inconsistent law
Immunizations
Vaccines
Influenza
Pneumonia
Hepatitis A
Hepatitis B
Zoster
Tetanus
Td
Tdap
Vaccines
Pursuant to prescription or written protocol
Pursuant to a lawful order of a practitioner and in accordance with written protocols
Pursuant to a written protocol based on a collaborative practice agreement or a
patient-specific prescription from a licensed prescriber
Pursuant to a protocol submitted to the board
May administer under pharmacist authority
May administer under pharmacist authority
Wyoming
19+
without any
contraindication
Pursuant to an order of a prescribing practitioner
Must participate in the Vaccines for Children Program and administer under protocols
approved by the Oregon Health Authority
Pursuant to a written physician-approved protocol
Td
Pursuant to Board authorization
Tdap
MMR
Varicella
19+ with an
Influenza
absolute or
Pneumococcal
Pursuant to a prescription from a licensed physician
relative
Hepatitis A
contraindication Hepatitis B
Meningococcal
HPV
Zoster
Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice—Fall 2013
48
PHYSICIAN ASSISTANTS
All 51 jurisdictions address how physician assistants (PAs) are authorized to assess
patients, issue prescriptions, or administer vaccines. See Table 8 and Figure 10 below.
Authority to Assess Patient Status
Twenty six states address how PAs may assess patient status (Alaska, Arizona,
California, Colorado, Delaware, DC, Florida, Iowa, Louisiana, Maryland, Massachusetts,
Michigan, Minnesota, Mississippi Missouri, Montana, Nevada, New Jersey, Ohio, Oklahoma,
South Dakota, Texas, Utah, Virginia, West Virginia, and Wisconsin). These states permit PAs to
conduct assessments only under delegated authority.
No state prohibits assessments and no state addresses whether a PA may assess patients
under their own license. The excerpt from Arizona is common among the states:
A. A supervising physician may delegate health care tasks to a physician assistant. . . . C. The
physician assistant may perform those duties and responsibilities, including the ordering,
prescribing, dispensing and administration of drugs and medical devices that are delegated by the
supervising physician. D. The physician assistant may provide any medical service that is
delegated by the supervising physician if the service is within the physician assistant's skills, is
within the physician's scope of practice and is supervised by the physician. . . .
G. The physician assistant may perform health care tasks in any setting authorized by the
supervising physician . . . These tasks may include: 1. Obtaining patient histories. 2. Performing
physical examinations. 3. Ordering and performing diagnostic and therapeutic procedures. 4.
Formulating a diagnostic impression. 5. Developing and implementing a treatment plan. 6.
Monitoring the effectiveness of therapeutic interventions. . . . 9. Making appropriate referrals. 10.
Prescribing schedule . . . and prescription-only medications. . . . 13. Performing other nonsurgical
health care tasks that are normally taught in courses of training approved by the board, that are
consistent with the training and experience of the physician assistant and that have been properly
delegated by the supervising physician. . . . Ariz. Rev. Stat. § 32-2531 (2012) Physician assistant
scope of practice; health care tasks; supervising physician duties; civil penalty
Authority to Prescribe Vaccines
All states except Iowa allow PAs to prescribe medications or vaccines under delegated
authority. No state grants prescriptive authority under a PA’s own license. No state prohibits
PAs from issuing prescriptions. The provision from Arkansas illustrates the expansive powers
that have been delegated to the PA:
(a) Physician assistants provide health care services with physician supervision. The supervising
physician shall be identified on all prescriptions and orders. Physician assistants may perform
those duties and responsibilities, including the prescribing, ordering, and administering drugs
and medical devices, that are delegated by their supervising physicians. (b) Physician
assistants shall be considered the agents of their supervising physicians in the performance of
all practice-related activities, including, but not limited to, the ordering of diagnostic,
therapeutic, and other medical services. (c) Physician assistants may perform health care
49
services in any setting authorized by the supervising physician in accordance with any
applicable facility policy. Ark. Code § 17-105-107 (2012) Scope of authority—Delegatory
authority—Agent of supervising physician
(a) Physicians supervising physician assistants may delegate prescriptive authority to physician
assistants to include prescribing, ordering, and administering . . . all legend drugs, and all
nonschedule prescription medications and medical devices. All prescriptions and orders
issued by a physician assistant shall also identify his or her supervising physician. . . . Ark.
Code § 17-105-108 (2012) Prescriptive authority
(a) Patient care orders generated by a physician assistant shall be construed as having the same
medical, health, and legal force and effect as if the orders were generated by their supervising
physician, provided that the supervising physician's name is identified in the patient care
order. (b) The orders shall be complied with and carried out as if the orders had been issued
by the physician assistant's supervising physician. Ark. Code § 17-105-122 (2012) Physician
assistant patient care orders
Authority to Administer Vaccines
Thirty-five states permit PAs to administer legend drugs, medications, injections, or
vaccines under delegated authority. The states are Alabama, Alaska, Arizona, Arkansas,
California, Colorado, Connecticut, Delaware, DC, Hawai’i, Idaho, Illinois, Indiana, Iowa,
Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi,
Montana, Nevada, New Hampshire, New Jersey, New Mexico, Oklahoma, Oregon,
Pennsylvania, South Dakota, Texas, Virginia, Wisconsin, and Wyoming.
No state permits PAs to administer medications under independent authority and no state
prohibits PAs from administering medications. Examples from Delaware and South Dakota are
below:
(h) Prescription and nonprescription medications may be initiated by standing orders if these
standing orders have been approved by the supervising physician. . . 24 Del. Code § 1771 (2012)
Physician's duties in supervision of a physician assistant
***
Except for . . . immunizations . . . provided by . . . a physician's assistant are reimbursed at 90
percent of the physician's fee. . . . Reimbursement for . . . immunizations . . . provided by . . . a
physician's assistant are reimbursed according to [rules related to the rate of payment]. Admin.
Rules of S.D. 67:16:02:15 (2012) Reimbursement for services provided by nurse practitioner,
clinical nurse specialist, or physician’s assistant
Defining Patients who May Receive Vaccinations
California and Colorado are the two states that have specified the patient populations
eligible to receive vaccines from PAs. The following quotes show that California permits PAs to
vaccinate students against influenza under standing orders, after parental consent, and with
notification of the school nurse. In Colorado, PAs may vaccinate patients up to age 13:
(a) . . . [T]he [governing board of a school district] may permit a licensed physician and surgeon,
or a health care practitioner listed in subdivision (b) who is acting under the direction of a
supervising physician and surgeon, to administer an immunizing agent to a pupil whose parent or
guardian has consented in writing to the administration of the immunizing agent.
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(b)(1) The following health care practitioners, acting under the direction of a supervising physician
and surgeon, may administer an immunizing agent within the course of a school immunization
program: (A) A physician assistant. . . .
(2) A health care practitioner's authority to administer an immunizing agent pursuant to this
subdivision is subject to the following conditions: (A) The administration of an immunizing agent
is upon the standing orders of a supervising physician and surgeon and in accordance with any
written regulations that the State Department of Public Health may adopt.
(B) The school nurse is notified and he or she maintains control, as necessary, as supervisor of
health . . . .
(C) The health care practitioner may only administer immunizations for the prevention and control
of any of the following: (i) Annual seasonal influenza. (ii) Influenza pandemic episodes. (iii)
Other diseases that represent a current or potential outbreak as declared by a federal, state, or local
public health officer. Cal. Education Code § 49403 (2012) Cooperation in control of
communicable disease and immunization of pupils
***
. . . (11) Child health supervision services. (a) For purposes of this subsection (11), unless the
context otherwise requires, “child health supervision services” means those preventive services
and immunizations required to be provided in basic and standard health benefit plans . . . to
dependent children up to age thirteen. Such services shall be provided by a physician or pursuant
to a physician's supervision or by a primary health care provider who is a physician's assistant . . .
who has additional training in child health assessment and who is working in collaboration with a
physician. Colo. Rev. Stat. § 10-16-104 (2012) Mandatory coverage provisions—definitions
Level of Supervision Required to Practice
All 51 states indicate how PAs are to be supervised. The excerpts from Georgia,
Missouri and Wisconsin provide examples of how the scope of PA practice is limited by the
supervising physician:
(7) “Physician assistant” [may] provide patients' services not necessarily within the physical
presence but under the personal direction or supervision of the supervising physician. Code of Ga.
§ 43-34-102 (2012) Definitions
(e.1)(1) . . . [A] physician may delegate to a physician assistant . . . the authority to issue a
prescription drug order or orders for any device . . . or to issue any dangerous drug . . . on a
prescription drug order or prescription device order form . . . . Delegation of such authority shall
be contained in the job description required by this Code section. The delegating physician shall
remain responsible for the medical acts of the physician assistant performing such delegated acts
and shall adequately supervise the physician assistant. If an existing job description for a physician
assistant does not contain such authority to order a prescription drug or device order as provided
by this subsection, that physician assistant may not issue any such prescription drug or device
order until a new job description delegating such authority is submitted to and approved by the
board. . . . .
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***
1. [T]he following terms mean . . . (8) “Supervision”, control exercised over a physician assistant
working within the same facility as the supervising physician sixty-six percent of the time a
physician assistant provides patient care, except a physician assistant may make follow-up patient
examinations in hospitals, nursing homes, patient homes, and correctional facilities, each such
examination being reviewed, approved and signed by the supervising physician . . . . Mo. Stat.
334.735 (2012) Definitions--rules--scope of practice--prohibited activities--board of healing
arts to administer licensing program--supervision agreements--duties and liability of physicians
. . . (5) The on-site supervision . . . shall not apply when a physician assistant is making follow-up
patient examinations in hospitals, patient homes, nursing homes and correctional facilities without
a supervising physician's presence. . . . 20 Mo. Code of State Regs. 2150-7.135 (2012) Physician
Assistant Supervision Agreements
***
(1) Scope and limitations. In providing medical care, the entire practice of any physician assistant
shall be under the supervision of a licensed physician. The scope of practice is limited to providing
medical care specified in sub. (2). A physician assistant's practice may not exceed his or her
educational training or experience and may not exceed the scope of practice of the supervising
physician. . . . (2) Medical care. Medical care a physician assistant may provide include: (a)
Attending initially a patient of any age in any setting to obtain a personal medical history, perform
an appropriate physical examination, and record and present pertinent data concerning the patient
in a manner meaningful to the supervising physician. (b) Performing, or assisting in performing,
routine diagnostic studies as appropriate for a specific practice settin[g]. (c) Performing routine
therapeutic procedures, including, but not limited to, injections, immunizations . . . (i) Issuing
written prescription orders for drugs under the supervision of a licensed physician. . . . Wis.
Admin. Code Med 8.07 (2012) Practice
Settings where Physician Assistants are Authorized to Vaccinate
Thirty-eight states permit PAs to practice in a broad range of settings. The states are:
Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawai’i,
Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Michigan, Missouri, Nebraska, New
Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio,
Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia,
Washington, Wisconsin, West Virginia, and Wyoming.
Permissible settings include a wide range of clinical and community locations: any
setting in which the supervising physician agrees to provide supervision, acute care hospitals and
other health care facilities, designated health manpower shortage areas, rural health clinics,
Federally Qualified Health Centers, county health departments, patient’s homes, ambulances,
school health fairs, industrial sites, wellness clinics, and correctional facilities.
Excerpts from Texas provide an example of the array of permissible settings:
(a) . . . “primary practice site” means: (1) the practice location . . . at which the physician spends
the majority of the physician’s time; (2) a licensed hospital, a licensed long-term care facility, or a
licensed adult care center . . . (3) a clinic operated by or for the benefit of a public school district .
. . (4) the residence of an established patient; (5) another location at which the physician is
physically present with the physician assistant . . . or (6) a location where a physician assistant . . .
who practices on-site with the physician more than 50 percent of the time . . . (A) health care
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services for established patients; (B) . . . voluntary charity health care services at a clinic run or
sponsored by a nonprofit organization; or (C) . . . voluntary health care services during a declared
emergency or disaster at a temporary facility operated or sponsored by a governmental entity or
nonprofit organization and established to serve persons in this state. (b) At a physician's primary
practice site. . . . Tex. Stat. & Codes § 157.053 (2012) Prescribing at Physician Primary
Practice Sites; see also Tex. Stat. & Codes § 157.054 (2012) Prescribing at Facility-Based
Practice Sites
. . . (c) The activities . . . may be performed in any place authorized by a supervising physician,
including a clinic, hospital, ambulatory surgical center, patient home, nursing home, or other
institutional setting. . . . Tex. Stat. & Codes § 204.202 (2012) Scope of Practice
(a) . . . (4) “Site serving a medically underserved population” means: (A) a site located in a
medically underserved area; (B) a site located in a health manpower shortage area; (C) a clinic
designated as a rural health . . . (D) a public health clinic or a family planning clinic under contract
with the Texas Department of Human Services or the Texas Department of Health; (E) a site
located in an area in which the Texas Department of Health determines there is an insufficient
number of physicians providing services to eligible clients of federal, state, or locally funded
health care programs; or (F) a site that the Texas Department of Health determines serves a
disproportionate number of clients eligible to participate in federal, state, or locally funded health
care programs. . . . Tex. Stat. & Codes § 157.052 (2012) Prescribing at Sites Serving Certain
Medically Underserved Populations
. . . (b) A physician may delegate to any qualified and properly trained person acting under the
physician's supervision the act of administering or providing dangerous drugs in the physician's
office. . . . (c) A physician may also delegate to any qualified and properly trained person acting
under the physician's supervision the act of administering or providing dangerous drugs through a
facility licensed by the Texas State Board of Pharmacy, as ordered by the physician, that are used
or required to meet the immediate needs of the physician's patients. . . . Tex. Stat. & Codes §
157.002 (2012) General Delegation of Administration and Provision of Dangerous Drugs
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Table 8: STANDING ORDERS: Physician Assistants & Immunization Practice
STATE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawai’i
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Mass.
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
N Hamp.
N Jersey
N Mexico
N York
N Carolina
N Dakota
Ohio
Oklahoma
Oregon
Penn.
R Island
S Carolina
S Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
W Virginia
Wisconsin
Wyoming
Own
Authority
ASSESSMENT
Delegated
Authority
●
●
●
●
●
●
●
●
Prohibited
Own
Authority
PRESCRIPTION
Delegated
Prohibited
Authority
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Own
Authority
ADMINISTRATION
Delegated
Prohibited
Authority
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Source: GWU/SPHHS STANDING ORDERS: Health Professionals & Immunization Practice—Fall 2013
54
Figure 10 – Physician Assistants
Physician Assistants are most frequently permitted to administer legend drugs followed by medications.
.
Wisconsin
Influenza
California
Massachusetts (seasonal, H1N1)
Drugs or Legend Drugs/Substances
Alabama
Arizona
Arkansas
California
Connecticut
DC
Hawai’i
Indiana
Kansas
Kentucky
Maryland
Minnesota
Mississippi
Montana
Nevada
New Hampshire
New Mexico
Oklahoma
Pennsylvania
Texas
Injectable Medication/Inoculation
New Jersey
Oklahoma
Virginia
Wisconsin
Pharmacological Agents
Mississippi
Schedule VI Controlled Substances
(includes any substance requiring a
prescription)
Virginia
Medications
Alabama
Arkansas
California
Delaware
Hawai’i
Louisiana
Mississippi
New Jersey
Oregon
Wyoming
Immunizations or Vaccines
California
Hawai’i
Illinois
Iowa
Michigan
Oklahoma
South Dakota
Texas
55