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Feb 4 2016

NCMB Position Statements: 2015 changes and year in review

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Each year, in the Winter issue of the Forum, NCMB highlights recent changes to the Board’s official position statements. Position statements are an important resource for licensees that provide guidance on a range of subjects, including direct clinical practice, professional ethics, legal and policy matters and other practice related topics. This article focuses on position statements that were either revised in 2015 or that were reviewed and approved with no changes. The Board did not adopt any new position statements last year.

A downloadable pdf copy of the complete position statements is available online. Individual statements are also posted online. Access them by clicking here.

Advisory statement
What are the position statements of the Board and to whom do they apply?

The North Carolina Medical Board’s Position Statements are interpretive statements that attempt to define or explain the meaning of laws or rules that govern the practice of physicians,* physician assistants, and nurse practitioners in North Carolina, usually those relating to discipline. They also set forth criteria or guidelines used by the Board’s staff in investigations and in the prosecution or settlement of cases.

When considering the Board’s Position Statements, the following four points should be kept in mind:
    • In its Position Statements, the Board attempts to articulate some of the standards it believes applicable to the medical profession and to the other health care professions it regulates. However, a Position Statement should not be seen as the promulgation of a new standard as of the date of issuance or amendment. Some Position Statements are reminders of traditional, even millennia old, professional standards, or show how the Board might apply such standards today.
    • The Position Statements are not intended to be comprehensive or to set out exhaustively every standard that might apply in every circumstance. Therefore, the absence of a Position Statement or a Position Statement’s silence on certain matters should not be construed as the lack of an enforceable standard.
    • The existence of a Position Statement should not necessarily be taken as an indication of the Board’s enforcement priorities.
    • A lack of disciplinary actions to enforce a particular standard mentioned in a Position Statement should not be taken as an abandonment of the principles set forth therein.

The Board will continue to decide each case before it on all the facts and circumstances presented in the hearing, whether or not the issues have been the subject of a Position Statement. The Board intends that the Position Statements will reflect its philosophy on certain subjects and give licensees some guidance for avoiding Board scrutiny. The principles of professionalism and performance expressed in the Position Statements apply to all persons licensed and/ or approved by the Board to render medical care at any level.

*The words “physician” and “doctor” as used in the Position Statements refer to persons who are MDs or DOs licensed by the Board to practice medicine and surgery in North Carolina.

Position statements revised in 2015
    • Contact with patients before prescribing: This position statement was revised to address needed exceptions for hospice care providers
    • HIV/HBV infected health care workers: This position statement was revised to reflect the most current version of the relevant administrative rule
    • Physician supervision of other licensed health care practitioners: This position statement revised to include paragraph on maintaining proper boundaries.

The full text of the revised versions of each position statement is published below.

Contact with patients before prescribing
It is the position of the North Carolina Medical Board that prescribing drugs to an individual the prescriber has not examined to the extent necessary for an accurate diagnosis is inappropriate except as noted in the paragraphs below. Before prescribing a drug, a licensee should make an informed medical judgment based on the circumstances of the situation and on his or her training and experience. Ordinarily, this will require that the licensee perform an appropriate history and physical examination, make a diagnosis, and formulate a therapeutic plan, a part of which might be a prescription. This process must be documented appropriately.

Prescribing for a patient whom the licensee has not personally examined may be suitable under certain circumstances. These may include admission orders for a newly hospitalized patient, interim medication orders or prescriptions, including pain management, from a hospice physician for a patient admitted to a certified hospice program, prescribing for a patient of another licensee for whom the prescriber is taking call, continuing medication on a short-term basis for a new patient prior to the patient’s first appointment, an appropriate prescription in a telemedicine encounter where the threshold information to make an accurate diagnosis has been obtained, prescribing an opiate antagonist to someone in a position to assist a person at risk of an opiate-related overdose, or an appropriate prescription in anticipation of a diagnostic test consistent with the standard of care in that particular specialty . Established patients may not require a new history and physical examination for each new prescription, depending on good medical practice.

Prescribing for an individual whom the licensee has not met or personally examined may also be suitable when that individual is the partner of a patient whom the licensee is treating for gonorrhea or chlamydia. Partner management of patients with gonorrhea or chlamydia should include the following items:
    • Signed prescriptions of oral antibiotics of the appropriate quantity and strength sufficient to provide curative treatment for each partner named by the infected patient. Notation on the prescription should include the statement: “Expedited partner therapy.”
    • Signed prescriptions to named partners should be accompanied by written material that states that clinical evaluation is desirable; that prescriptions for medication or related compounds to which the partner is allergic should not be accepted; and that lists common medication side effects and the appropriate response to them.
    • Prescriptions and accompanying written material should be given to the licensee’s patient for distribution to named partners.
    • The licensee should keep appropriate documentation of partner management. Documentation should include the names of partners and a copy of the prescriptions issued or an equivalent statement.

It is the position of the Board that prescribing drugs to individuals the licensee has never met based solely on answers to a set of questions, as is common in Internet or toll-free telephone prescribing, is inappropriate and unprofessional.

(Adopted: Nov 1, 1999) (Modified: February 2001; November 2009, May 2013, November 2014, March 2015, July 2015)

CHIV/HBV infected health care workers
The North Carolina Medical Board supports and adopts the following rules of the North Carolina Department of Health and Human Services regarding infection control in health care settings and HIV/HBV infected health care workers.
10A NCAC 41A .0206 INFECTION PREVENTION – HEALTH CARE SETTINGS (a) The following definitions apply throughout this Rule:
(1) “Health care organization” means a hospital; clinic; physician, dentist, podiatrist, optometrist, or chiropractic office; home care agency; nursing home; local health department; community health center; mental health facility; hospice; ambulatory surgical facility; urgent care center; emergency room; Emergency Medical Service (EMS) agency; pharmacies where a health practitioner offers clinical services; or any other organization that provides clinical care.
(2) “Invasive procedure” means entry into tissues, cavities, or organs or repair of traumatic injuries. The term includes the use of needles to puncture skin, vaginal and cesarean deliveries, surgery, and dental procedures during which bleeding occurs or the potential for bleeding exists.
(3) “Non-contiguous” means not physically connected.
(b) In order to prevent transmission of HIV, hepatitis B, hepatitis C and other bloodborne pathogens each health care organization that performs invasive procedures shall implement a written infection control policy. The health care organization shall ensure that health care workers in its employ or who have staff privileges are trained in the principles of infection control and the practices required by the policy; require and monitor compliance with the policy; and update the policy as needed to prevent transmission of HIV, hepatitis B, hepatitis C and other bloodborne pathogens. The health care organization shall designate one on-site staff member for each noncontiguous facility to direct these activities. The designated staff member in each health care facility shall complete a course in infection control approved by the Department. The Department shall approve a course that addresses:
(1) Epidemiologic principles of infectious disease;
(2) Principles and practice of asepsis;
(3) Sterilization, disinfection, and sanitation;
(4) Universal blood and body fluid precautions;
(5) Safe injection practices;
(6) Engineering controls to reduce the risk of sharp injuries;
(7) Disposal of sharps; and
(8) Techniques that reduce the risk of sharp injuries to health care workers.
(c) The infection control policy required by this Rule shall address the following components that are necessary to prevent transmission of HIV, hepatitis B, hepatitis C and other bloodborne pathogens:
(1) Sterilization and disinfection, including a schedule for maintenance and microbiologic monitoring of equipment; the policy shall require documentation of maintenance and monitoring;
(2) Sanitation of rooms and equipment, including cleaning procedures, agents, and schedules;
(3) Accessibility of infection control devices and supplies; and
(4) Procedures to be followed in implementing 10A NCAC 41A .0202(4) and .0203(b)(4) when a health care provider or a patient has an exposure to blood or other body fluids of another person in a manner that poses a significant risk of transmission of HIV or hepatitis B.
(d) Health care workers and emergency responders shall, with all patients, follow Centers for Disease Control and Prevention Guidelines on blood and body fluid precautions incorporated by reference in 10A NCAC 41A .0201.
(e) Health care workers who have exudative lesions or weeping dermatitis shall refrain from handling patient care equipment and devices used in performing invasive procedures and from all direct patient care that involves the potential for contact of the patient, equipment, or devices with the lesion or dermatitis until the condition resolves.
(f) All equipment used to puncture skin, mucous membranes, or other tissues in medical, dental, or other settings must be disposed of in accordance with 15A NCAC 13B .1200 after use or sterilized prior to reuse.

History Note: Authority G.S. 130A-144; 130A-145; 130A-147; Eff. October 1, 1992; Amended Eff. January 1, 2010; December 1, 2003; July 1, 1994; January 4, 1994.

Physician supervision of other licensed health care practitioners
The physician who provides medical supervision of other licensed healthcare practitioners is expected to provide adequate oversight. The physician must always maintain the ultimate responsibility to assure that high quality care is provided to every patient. In discharging that responsibility, the physician should exercise the appropriate amount of supervision over a licensed healthcare practitioner which will ensure the maintenance of quality medical care and patient safety in accord with existing state and federal law and the rules and regulations of the North Carolina Medical Board. What constitutes an “appropriate amount of supervision” will depend on a variety of factors. Those factors include, but are not limited to:
• The number of supervisees under a physician’s supervision
• The geographical distance between the supervising physician and the supervisee
• The supervisee’s practice setting
• The medical specialty of the supervising physician and the supervisee
• The level of training of the supervisee
• The experience of the supervisee
• The frequency, quality, and type of ongoing education of the supervisee
• The amount of time the supervising physician and the supervisee have worked together
• The quality of the written collaborative practice agreement, supervisory arrangement, protocol or other written guidelines intended for the guidance of the supervisee
• The supervisee’s scope of practice consistent with the supervisee’s education, national certification and/or collaborative practice agreement

Physicians should also be cognizant of maintaining appropriate boundaries with their supervisees, including refraining from requesting medical treatment by the physician’s supervisee. Physician assistants and nurse practitioners are specifically prohibited from prescribing controlled substances for the use of their supervising physicians.

Practices owned solely by physician assistants or nurse practitioners may not hire or contract with physicians to practice medicine on behalf of the physician assistant or nurse practitioner owned practice. The physician assistant or nurse practitioner may contract with a physician to provide the legally required supervision of the physician assistant or nurse practitioner.

(Adopted July 2007)(Reviewed September 2012)(Revised November 2015) See also the Board’s position statement on “Self-treatment and Treatment of Family Members.”

The following position statements were reviewed in 2015 and approved by the Board with no changes:
• Competence and Reentry to the Active Practice of Medicine
• Laser Surgery
• Prescribing Controlled Substances for Other Than Valid Medical or Therapeutic Purposes, with Particular Reference to Substances or Preparations with Anabolic Properties
• Referral fees and fee splitting
• Sale of goods from physician offices
• Writing of prescriptions

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