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Scope of Practice

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  • 1. PHYSICIAN ASSISTANT PILOT IN THE NORTHERN REGION DISTRICT HEALTH BOARDS, NEW ZEALAND Governance Document No. 3 Physician Assistant Scope of Practice Note: This Scope of Practice is Prepared Specifically for the Physician Assistant Pilot in General Surgery at CMDHB Scope of Practice Supervision (refer also attached notes) The Physician Assistant will work under the delegation and supervision of a vocationally registered medical practitioner (SMO in DHB setting). The supervising medical practitioner(s) will remain responsible for the overall management of the patient, and for their decision to delegate and the level and nature of the supervision they provide. In this regard they determine the scope of duties and responsibilities of the Physician Assistant. Authorised Activities Detailed below are activities intended to provide a representative summary of the major activities the Physician Assistant may perform but are not intended to serve as a comprehensive list of all duties performed. The activities may be performed under different levels of supervision (refer attached notes). a. Obtain comprehensive case histories b. Undertake physical examinations of specified areas c. Collect blood samples, insert luers, catheters d. Order simple radiology e. Interpret results of investigations f. Formulate a working diagnosis g. Develop a treatment plan h. Initiate and monitor treatment after consultation with supervisor i. Perform procedures as designated by supervisor j. Attend ward rounds/patient reviews k. Present patients on ward rounds l. Record notes/instructions from the supervisor or other designated medical practitioner approved by the supervisor m. Order investigations requested by the supervisor or other designated medical practitioner approved by the supervisor n. Follow up investigations o. Assist with documentation, including discharge summaries, operating lists p. Attend clinics or operating lists at the direction of the supervisor q. Undertake other duties as delegated by the supervisor Prescribing/Supplying/Administering Medication The Physician Assistant will not be authorised to prescribe medication or sign a prescription. The Physician Assistant will be permitted to administer some medications under standing orders or at the direction of the authorised prescriber, according to specified protocols. The Physician Assistant will not be permitted to administer controlled drugs under any circumstances. Version 8 (200410) 1
  • 2. Radiology The Physician Assistant will be permitted to request simple radiology and some USS, according to specified protocols. More complex radiology such as CT/MRI and more complex USS can be ordered under the authorisation of a member of the medical team (SMO, registrar). Blood and Blood Products The Physician Assistant will be permitted to order blood and blood products under the authorisation of a member of the medical team (SMO, RMO). Exclusions For the purposes of the pilot, the Physician Assistant will not be permitted to: • Prescribe medication or sign a prescription. • Administer controlled drugs. • Order complex radiology investigations such as CT/MRI and more complex USS, unless authorised by a member of the medical team (SMO, registrar). • Order blood and blood products, unless authorised by a member of the medical team (SMO, RMO). • Obtain patient consents • Sign a death certificate. • Sign ACC and Medical Certificate forms. • Perform any activities which are restricted to registered health professionals under the Health Practitioners Competence Assurance Act 2003 (Health Practitioners Competence Assurance (Restricted Activities) Order 2005), ie, § Surgical or operative procedures below the gingival margin or the surface of the skin, mucous membranes, or teeth. § Clinical procedures involved in the insertion and maintenance of fixed and removable orthodontic or oral and maxillofacial prosthetic appliances. § Prescribing of enteral or parenteral nutrition where the feed is administered through a tube into the gut or central venous catheter. § Prescribing of an ophthalmic appliance, optical appliance, or ophthalmic medical device intended for remedial or cosmetic purposes or for the correction of a defect of sight. § Applying high-velocity, low-amplitude manipulative techniques to cervical spinal joints. • Perform any medical service, procedure, function or activity which is outside of the assigned role. Immediate Consultation The Physician Assistant must immediately seek consultation with the supervisor or other appropriate medical staff where: • A registered medical practitioner or nurse in charge requests them to do so • There is uncertain diagnosis • The condition exceeds his/her ability • The patient does not respond as expected to therapy • The patient fails to respond to therapy • The patient desires to see a doctor Version 8 (200410) 2
  • 3. Notes to Scope of Practice Summary Notes Relating to the Supervision and Management of the Physician Assistants (For full details refer to Governance Document 2 - Standards for the Supervision and Management of Physician Assistants) Assignment of Activities 1. Activities will be assigned to the Physician Assistant in accordance with the competencies of the Physician Assistant and the scope of practice of the supervisors. 2. Activities may be undertaken under different levels of supervision (refer point 7). 3. The Physician Assistant will only accept assigned activities that: • Can be provided by the service they are working in • Are within the scope of practice of his/her supervisors • He/she is competent to perform and which are consistent with the Physician Assistant’s education, training and experience. Supervision 4. The Physician Assistant will work under the delegation and supervision of a vocationally registered medical practitioner (SMO in DHB setting). The supervising medical practitioner(s) will remain responsible for the overall management of the patient, and for their decision to delegate and the level and nature of the supervision they provide. In this regard they determine the scope of duties and responsibilities of the Physician Assistant. 5. There will be designated primary and secondary supervisors for the Physician Assistant. 6. The Physician Assistant will be assigned to a team, including a supervising SMO and associated RMOs. The Physician Assistant will work collaboratively with other health professionals as a member of the broader multidisciplinary health care team. 7. The Physician Assistant will work under direct and/or indirect supervision. Under both direct and indirect supervision, the supervising SMO will retain responsibility for the overall management of the patient. At all times, the Physician Assistant will provide treatment to patients at the direction of the supervising SMO or, in unusual circumstances, at the direction of another medical practitioner designated and approved by the primary supervisor. • Under direct supervision: A supervisor is present and observes, works with and directs the Physician Assistant. Direct supervision continues until in the opinion of the primary supervisor the Physician Assistant has the skills and competence to move to indirect supervision. When working under direct supervision the Physician Assistant is required to discuss each case individually with the supervisor or other designated medical practitioner approved by the supervisor. • Under indirect supervision: A supervisor is working at either Middlemore or Manukau Health Park (MHP) but is not constantly observing the Physician Assistant’s activities. The Physician Assistant is periodically permitted to work alone, but must have telephone access to a supervisor or (in unusual circumstances) to another designated medical practitioner approved by the primary supervisor. While the direct line of supervision and accountability will lie with the supervisor, for practical purposes, immediate oversight will often be by the registrar, as approved and designated by the supervisor. 8. There must be a supervisor available for consultation with the Physician Assistant at all times either in person or through telecommunication systems or other means. In unusual Version 8 (200410) 3
  • 4. circumstances, another medical practitioner may be designated and approved by the primary supervisor to be available. 9. The primary supervisor will determine the level of supervision required before assigning the activity to the Physician Assistant. The primary supervisor may delegate this responsibility to a secondary supervisor. 10. In determining the level of supervision required, the supervisor will consider; • the complexity of the activity • the nature of the practice setting • the competence and experience of the Physician Assistant 11. The level of supervision required will be dependent on the skills and competence of the Physician Assistant and the developing relationship with the supervisors. The level of supervision may vary from time to time. The level of supervision will remain under the ongoing review of the clinical governance committee. 12. The primary supervisor (or a secondary supervisor in the absence of the primary supervisor) will retain the right to immediately limit or reduce the scope of practice or increase the level of supervision, should they have concerns about the practice of the Physician Assistant. This action will be reported as soon as practicable to the clinical governance committee. Practice Plan 13. A written practice plan will be developed for each Physician Assistant with his/her primary supervisor. This plan will include details of the scope of practice, authorised activities, excluded activities and supervision arrangements specific to the Physician Assistant (eg, the activities that can be undertaken under indirect supervision and the activities that can be undertaken only under direct supervision). 14. The practice plan will be signed by the Physician Assistant and his/her primary and secondary supervisors, and submitted to the clinical governance committee for approval. Changes to the practice plan will require specific written amendment and the formal approval of the clinical governance committee. Review 15. There will be a requirement for regular and frequent formal and informal reviews between the Physician Assistant and his/her supervisors which will be designated in the practice plan. Reports from the formal review meetings will be forwarded to the clinical governance committee. 16. Under direct supervision: A supervisor will meet with the Physician Assistant at end of each day to review cases, for the first week. This will involve a chart review. After the first week, reviews can move to weekly meetings at the discretion of the supervisor. This will continue until the Physician Assistant formally moves to indirect supervision. 17. Under indirect supervision: Weekly informal meetings will be maintained. These may be by phone. 18. The Physician Assistant will keep a logbook of activities. These will be reviewed weekly with the primary supervisor. The primary supervisor may delegate this responsibility to a secondary supervisor from time to time. 19. Formal meetings with the primary supervisor will be held monthly for the first 3 months and thereafter 3 monthly. Reviews to include a review of charts. Version 8 (200410) 4