Kansas PA Regulations Pertaining to Direction and Supervision

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December 22, 2006

Lawrence T. Buening, Jr, Executive Director

Kansas State Board of Healing Arts
235 S. Topeka Boulevard

Topeka, KS 66603-3068

Dear Mr. Buening:

The American Academy of Physician Assistants is the national professional society for physician assistants (PAs). In this capacity, the Academy represents over 60,000 physician assistants in the United States. The Academy would like to comment on the Kansas State Board of Healing Arts proposed change to K.A.R. 100-28a-10, entitled “Supervision and Direction; Adequacy.” The board’s proposal seeks to add the following to the definition of “Supervision and Direction”:

7.           Determines whether or not the physician assistant has performed patient services constituting the practice of medicine and surgery with reasonable skill and safety, including whether or not any drug prescribed by the physician assistant was clinically indicated and whether or not the prescription order was appropriate.

 

10.(b)     To make the determination required by paragraph (a)(7), the responsible physician shall periodically review an adequate number of patient records documenting the treatment provided by the physician assistant. The review shall be considered to be periodic if it occurs at least once every 14 days. The number of records reviewed shall be considered to adequate if the responsible physician reviews the records for at least 25 percent of the total number of patients treated by the physician assistant during the period under review.

 

The board’s Notice of Proposed Rulemaking states that the rule is required to identify what is considered to be adequate direction and supervision of a physician assistant by the responsible physician.

PA and Physician Team – Role of Co-Signature Requirements

Physician assistants (PAs) have been practicing with physician supervision in Kansas since 1973. A physician assistant’s scope of practice is that of providing medical services under the supervision of a physician.

There are times when chart co-signature by physicians is appropriate. PAs have a responsibility to ensure that a supervising physician reviews complex problems and that the review is documented. However, the Academy believes the law should allow for flexibility for the supervising physician to determine when his or her countersignature is necessary on charts and medical orders written by a PA.

The earliest state laws for PAs commonly required physician co-signature of charts or orders; this was because of the novelty of the PA profession. But the American healthcare system now has 40 years of history with the physician-PA team.  Modern revisions of state laws have adapted the provisions, and, in many cases, removed co-signature requirements altogether.

Elimination of Restrictive Co-Signature Requirement is Best for Patients

The early state laws mandating the number of PA written chart entries to be signed by physicians were drafted to assure ongoing physician oversight. However, like many aspects of clinical medicine, the best patient care decisions are made not as blanket requirements in law, but rather as a customized response to individual practice situations.

A physician can more effectively care for patients when not burdened with such rigid regulations such as, mandated amounts of charts and orders to be reviewed. This allows the PA to see and treat patients with more minor illnesses,  allowing the physician  spend time with patients who require physician-level care and to review the work of the PA in a manner that is appropriate to the practice.

Conclusion

With due respect for the board’s concern for appropriate supervision, the Academy opposes adoption of the regulation as published. We believe chart co-signature requirements should be determined at the practice level.  This allows physicians greater flexibility to organize their own practice based on the education, skill, and experience of the physician assistant, the acuity of patients seen in the setting and the physician’s preferences.  The Academy would suggest an approach that allows the practice and any applicable institution to determine if and when physician co-signature is required.

Sincerely,

 Ramon Gardenhire, JD

Assistant Director, State Government Affairs