Rule 400
3 CCR 713-7

RULES AND REGULATIONS REGARDING THE LICENSURE OF AND PRACTICE BY PHYSICIAN ASSISTANTS (PAS)

INTRODUCTION

BASIS: The authority for promulgation of Rule 400 (“these Rules”) by the Colorado Medical Board (“Board”) is set forth in Sections 24-4-103, 12-36-104(1)(a),12-36-106(5) and 12-36-107.4, C.R.S.

PURPOSE: The purpose of these rules and regulations is to implement the requirements of Section 12-36-107.4 and 12-36-106(5) and provide clarification regarding the application of these rules to various practice settings.

SECTION 1. QUALIFICATIONS FOR LICENSURE APPLICATION 

A. To apply for a license, an applicant shall submit:

1. A completed Board-approved application and required fee; and

2. Proof of satisfactory passage of the national certifying examination for assistants to the primary care physician administered by the   National Commission on Certification of Physician Assistants.

SECTION 2. EXTENT AND MANNER IN WHICH A PHYSICIAN ASSISTANT MAY PERFORM DELEGATED TASKS CONSTITUTING THE PRACTICE OF MEDICINE UNDER PERSONAL AND RESPONSIBLE DIRECTION AND SUPERVISION

A. Responsibilities of the Physician Assistant

1. Compliance with these Rules. A physician assistant and the physician assistant’s supervising physician are responsible for implementing and complying with statutory requirements and the provisions of these Rules.

2. License. A physician assistant shall ensure that his or her license to practice as a physician assistant is active and current prior to performing any acts requiring a license.

3. Registration. A physician assistant shall ensure that a form in compliance with Section 4 of these Rules is on record with the Board.

4. Nameplate. While performing acts defined as the practice of medicine, a physician assistant shall wear a nameplate with the non-abbreviated title “physician assistant” clearly visible.

5. Chart Note. A physician assistant shall make a chart note for every patient for whom the physician assistant performs any act defined as the practice of medicine in Section 12-36-106(1), C.R.S. When a physician assistant consults with any physician about a patient, the physician assistant shall document in the chart note the name of the physician consulted and the date of the consultation. 

6. Documentation. A physician assistant shall keep such documentation as necessary to assist the supervising physician in performing an adequate performance assessment as set forth below in Section 2(C)(6) of these Rules.

7. Acute Care Hospital Setting

a. Physician assistants performing delegated medical functions in an acute care hospital setting must comply with the requirements of Section 12-36-106(5)(b)(II), C.R.S.

b. For purposes of this section, “reviewing the medical records” means review and signature by the primary physician supervisor or a secondary physician supervisor.

B. Types of Physician Supervisors and Scope and Authority to Delegate

1. Four Physician Assistant Limit. Except as otherwise provided in Section 2(E) of these Rules, no physician shall be the primary physician supervisor for more than four specific, individual physician assistants. The names of such physician assistants shall appear on the form in compliance with Section 4 of these Rules. The primary physician supervisor may supervise additional physician assistants other than those who appear on the form in compliance with Section 4 of these Rules. In other words, a primary physician supervisor may also be a secondary physician supervisor, as set forth below, for additional physician assistants so long as such supervision is in compliance with these Rules.

2. Primary Physician Supervisor. Except as set forth in Section 2(B)(3) of these Rules, a physician licensed to practice medicine by the Board may delegate to a physician assistant licensed by the Board the authority to perform acts that constitute the practice of medicine only if a form in compliance with Section 4 of these Rules is on record with the Board. The physician whose name appears on the form in compliance with Section 4 of these Rules shall be deemed the “primary physician supervisor”. The supervisory relationship shall be deemed to be effective for all time periods in which a form in compliance with Section 4 of these Rules is on file with the Board.

a. A physician assistant shall have  at least one  primary physician supervisor for each employer. If the employer is a multi-specialty organization, e.g., a multi-specialty practice, hospital, hospital system or health maintenance organization, the physician assistant shall have a primary supervisor, duly registered with the Board, per specialty practice area when performing delegated tasks consistent with the delegating physician’s education, training, experience, and active practice.

3. Secondary Physician Supervisors. A physician licensed to practice medicine by the Board, other than the supervisor whose name appears on the form in compliance with Section 4 of these Rules, may delegate to a physician assistant licensed by the Board the authority to perform acts which constitute the practice of medicine only as permitted by Section 2(D) of these Rules. Such physician shall be termed a “secondary physician supervisor”. Secondary physician supervisors do not need to be registered with the Board.

4. Delegation of Medical Services. Delegated services must be consistent with the delegating physician’s education, training, experience and active practice. Delegated services must be of the type that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. A physician may only delegate services that the physician is qualified and insured to perform and services that the physician has not been restricted from performing. Any services rendered by the physician assistant will be held to the same standard that is applied to the delegating physician. 

C. Responsibilities of and Supervision by the Primary Physician Supervisor

1. Compliance with these Rules. Both the supervising physician and the physician assistant are responsible for implementing and complying with the statutory requirements and the provisions of these Rules.

2. Liability for Actions of a Physician Assistant. A primary physician supervisor may supervise and delegate responsibilities to a physician assistant in a manner consistent with the requirements of these Rules. Except as provided in Sections 2(B)(3) and 2(D) of these Rules, the primary physician supervisor shall be deemed to have violated these Rules if a supervised physician assistant commits unprofessional conduct as defined in Section 12-36-117(1)(p), C.R.S., or if such physician assistant otherwise violates these Rules. The primary physician supervisor shall not be responsible for the conduct of a physician assistant where that physician assistant was acting under the supervision of another primary physician supervisor and there is a form in compliance with Section 4 of these Rules signed by that other primary physician supervisor. The primary physician supervisor shall also not be responsible for the conduct of a physician assistant where that physician assistant consulted with a secondary physician supervisor and documented such consultation in the chart note as required under Section 2(A)(5) of these Rules.

3. License Status. Before authorizing a physician assistant to perform any medical service, the supervising physician should verify that the physician assistant has an active and current Colorado license issued by the Board.

4. Qualifications. Before authorizing a physician assistant to perform any medical service, the supervising physician is responsible for evaluating the physician assistant’s education, training and experience to perform the service safely and competently.

5. Supervision

a. New physician assistant graduates – Must meet all of the following:

(1) For the first six months of employment and a minimum of 500 patient encounters, a physician supervisor shall review the chart for every patient seen by the physician assistant no later than seven days after the physician assistant has performed an act defined as the practice of medicine. The physician supervisor shall document the performance of such review by signing the chart in a legible manner. In lieu of signing the chart, the physician supervisor may document the performance of such review by the use of an electronically generated signature provided that reasonable measures have been taken to prevent the unauthorized use of the electronically generated signature.

(2) Additionally, a primary or secondary supervising physician of a new physician assistant graduate must provide on-site supervision of the new physician assistant graduate for that physician assistant’s first 1000 working hours.

(3) The supervising physician must complete a performance assessment as outlined in Section 2(C)(6) of these Rules by the end of the first six months of employment and quarterly thereafter for the first two years of employment. After the physician assistant has been working for more than two years, performance assessments must be completed twice each 12-month period for an additional three years. 

b. Experienced Physician Assistants New to a Practice Setting:

(1) The term “New to a Practice Setting” means for the purposes of this Rule:

(i) The change of the primary supervising physician and practice; or

(ii) A substantive change in scope of practice or practice area.

(2) Based on the years of active practice by the Physician Assistant, the following minimum activities must be performed:

(i)	A Physician Assistant with less than six months experience:

Follow new graduate requirements as set forth in Section 5(a) until the PA reaches a total of six months experience as a PA.

(ii) A Physician Assistant with more than six months but with less than five years’ experience:

For the first three months of employment and a minimum of 500 patient encounters, a physician supervisor shall review the chart for every patient seen by an experienced physician assistant new to a practice setting no later than 14 days after the physician assistant has performed an act defined as the practice of medicine. The physician supervisor shall document the performance of such review by signing the chart in a legible manner. In lieu of signing the chart, the physician supervisor may document the performance of such review by the use of an electronically generated signature provided that reasonable measures have been taken to prevent the unauthorized use of the electronically generated signature.

(iii) A Physician Assistant with five years and less than 10 years’ experience: 

For the first two months of employment and a minimum of 250 patient encounters, a physician supervisor shall review the chart for every patient seen by an experienced physician assistant new to a practice setting no later than 14 days after the physician assistant has performed an act defined as the practice of medicine. The physician supervisor shall document the performance of such review by signing the chart in a legible manner. In lieu of signing the chart, the physician supervisor may document the performance of such review by the use of an electronically generated signature provided that reasonable measures have been taken to prevent the unauthorized use of the electronically generated signature.

(iv) A Physician Assistant with 10 years or more experience:
For a minimum of 100 patient encounters, a physician supervisor shall review the chart for every patient seen by an experienced physician assistant new to a practice setting no later than 14 days after the physician assistant has performed an act defined as the practice of medicine. The physician supervisor shall document the performance of such review by signing the chart in a legible manner. In lieu of signing the chart, the physician supervisor may document the performance of such review by the use of an electronically generated signature provided that reasonable measures have been taken to prevent the unauthorized use of the electronically generated signature. 

(3) The supervising physician must complete a performance review for all physician assistants with less than 5 years’ experience in accordance with Section 2(C)(5)(a)(3). For all other physician assistants new to a practice setting, the supervising physician must complete a performance review by the end of the first six months and once each 12- month period thereafter.

(4) On site supervision for an experienced physician assistant, as defined in Section 2(C)(5)(b) and (c)of these Rules, is not required; instead it is at the discretion of the supervising physician.

c. All other Physician Assistants:

(1) The supervising physician shall meet with the physician assistant a minimum of one time during each 12-month period and conduct a performance assessment as set forth in Section 2(C)(6) of these Rules.

(2) On site supervision for an experienced physician assistant, as defined in Section 2(C)(5)(b) of these Rules, is not required; instead it is at the discretion of the supervising physician.

6. Performance Assessment

a. A physician who supervises a physician assistant shall develop and carry out a periodic performance assessment as required by these Rules to assist in evaluating and maintaining the quality of care provided by a physician assistant. The performance assessment must include but need not be limited to:

(1) An assessment of the medical competency of the physician assistant; 

(2) A review and initialing of selected charts;

(3) An assessment of a representative sample of the referrals or consultations made by the physician assistant with other health professionals as required by the condition of the patient;

(4) An assessment of the ability of the physician assistant to take a medical history from and perform an examination of patients representative of those cared for by the physician assistant; and

(5) Maintenance by the supervising physician of accurate records and documentation of the performance assessments for each physician assistant supervised.

b. The Board may audit a supervising physician’s performance assessment records. Upon request, the supervising physician shall produce records of the performance assessments as required by the Board. 

7. Availability of the physician supervisor

a. The supervising physician must provide adequate means for communication with the physician assistant.

b. If not physically on site with the physician assistant, the primary or secondary physician supervisor must be readily available by telephone, radio, pager, or other telecommunication device.

D. Responsibilities of the Secondary Physician Supervisor

1. If a physician who is not the primary physician supervisor consults with a physician assistant regarding a particular patient, the physician is a secondary physician supervisor. The physician assistant must document the consultation date and name of all physicians consulted in the patient chart.

2. Such physician shall be deemed to be responsible for any action or omission involving the practice of medicine supervised by the secondary physician supervisor involving the particular patient.

E. Waiver of Provisions of these Rules

1. Criteria for Obtaining Waivers.

a. Upon a showing of good cause, the Board may permit waivers of ANY provision of these Rules.

b. Factors to be considered in granting such waivers include, but are not limited to: whether the physician assistant is located in an underserved or rural area distant from the physician supervisor; the quality of protocols setting out the responsibilities of a physician assistant in the particular practice; any disciplinary history on the part of the physician supervisor or the physician assistant; and whether the physician assistants in question work less than a full schedule.

c. It is anticipated that waivers may be granted to permit a physician supervisor to supervise more than four physician assistants provided the Full Time Employee Equivalent is not more than four FTE and the physician is not supervising more than four physician assistants at any one time.

d. All such waivers shall be in the sole discretion of the Board. All waivers shall be strictly limited to the terms provided by the Board. No waivers shall be granted if in conflict with state law.

2. Procedure for Obtaining Waivers.

a. Applicants for waivers must submit a written application on forms approved by the Board detailing the basis for the waiver request.

b. The written request should address the pertinent factors listed in Section 2(E)(1)(b) of these Rules and include a copy of any written protocols in place for the supervision of physician assistants.

c. Upon receipt of the waiver request and documentation, the matter will be considered at the next available Board meeting. 

d. If a waiver to the four physician assistant limit is granted, the primary supervising physician must submit a revised form in compliance with Section 4 of these Rules containing the names of all physician assistants to be supervised before the waiver shall become effective.

SECTION 3. PRESCRIPTION AND DISPENSING OF DRUGS. 

A. Prescribing Provisions:

1. A physician assistant may issue a prescription order for any drug or controlled substance provided that:

a. Each prescription and refill order is entered on the patient’s chart.

b. Each written prescription order shall be signed by the physician assistant and shall contain in legible form the name, address and telephone number of the supervising physician and the name of the physician assistant.

c.  Each written prescription for a controlled substance shall contain, in legible form, the name of the physician assistant and the name, address and telephone number of the supervising physician.

d. For all other written prescriptions issued by a physician assistant, the physician assistant’s name and the address of the health facility where the physician assistant is practicing must by imprinted on the prescription.

	i. If the health facility is a multi-specialty organization, the name and address of the specialty clinic within the health facility where the physician assistant is practicing must be imprinted on the prescription.

e. Nothing in this Section 3 of these Rules shall prohibit a physician supervisor from restricting the ability of a supervised physician assistant to prescribe drugs or controlled substances.

f. A physician assistant may not issue a prescription order for any controlled substance unless the physician assistant has received a registration from the United States Drug Enforcement Administration.

g. For the purpose of this Rule electronic prescriptions are considered written prescription orders.

2. Physician assistants shall not write or sign prescriptions or perform any services that the supervising physician for that particular patient is not qualified or authorized to prescribe or perform.

B. Obtaining Prescription Drugs or Devices to Prescribe, Dispense, Administer or Deliver

1. No drug that a physician assistant is authorized to prescribe, dispense, administer or deliver shall be obtained by said physician assistant from a source other than a supervising physician, pharmacist or pharmaceutical representative.

2. No device that a physician assistant is authorized to prescribe, dispense, administer or deliver shall be obtained by said physician assistant from a source other than a supervising physician, pharmacist or pharmaceutical representative.

SECTION 4. REPORTING REQUIREMENTS 

A.	Supervisory Form.

1. Any person wishing to form a supervisory relationship in conformance with these Rules shall file with the Board a form as required by the Board.

2. The form shall be signed by the primary physician supervisor and the physician assistant or assistants for whom the physician intends to be the primary physician supervisor.

3. Except as provided by Board waiver, no primary physician supervisor shall be a primary physician supervisor for more than four specific, individual physician assistants.

4. Except as provided by Board waiver, the names of no more than four individual physician assistants shall appear on the form in compliance with this Section of these Rules. 

5. The supervisory relationship acknowledged in the form shall be deemed to continue for purposes of these Rules until specifically rescinded by either the physician assistant or the primary physician supervisor in writing.

Effective 12/30/83; Revised 05/30/85; Revised 12/30/85; Revised 8/30/92; Revised 11/30/94; Revised 12/1/95; Revised 12/14/95; Revised 3/30/96; Revised 3/30/97; Revised 9/30/97; Revised 3/30/98; Revised 9/30/98; Revised 06/30/00; Revised 12/30/01; Revised 9/30/04; Revised 2/9/06, Effective 3/31/06; Emergency Rule Revised and Effective 7/01/10; Revised 08/19/10, Effective 10/15/10; Revised 11/15/12, Effective 01/14/2013; Revised 5/22/14, Effective 7/15/14; Revised 8/20/15, Effective 10/15/15; Emergency Rule Revised And Effective 8/18/16; Permanent Rule Revised 8/18/16; Effective 10/15/16