- 4.01: Role of the Podiatrist
- 4.02: Drug Dispensing and Prescribing
- 4.03: Practice of Podiatric Medicine by Podiatric Medical Students
- 4.04: The Podiatric Medical Record
- 4.05: Documentation Guidelines and Medical Necessity
- 4.06: Proper Foot Care in a Skilled Nursing Home Facility
- 4.07: Initial Patient History and Physical Examination
- 4.08: General Anesthesia
- 4.09: Nitrous-Oxide-Oxygen Analgesia
- 4.10: Acceptable Standards of Care
4.01: Role of the Podiatrist
In the provision of podiatric care, the podiatrist examines, diagnoses and treats or prescribes course of treatment for patients with disorders, diseases or injuries of the foot and ankle; interviews patients and writes case histories to determine previous ailments, complaints and areas of investigation; examines footwear to determine proper fit, evidence of proper gait, and corrective care or treatment required; conducts complete physical examinations of the foot and ankle, including tissue, bone and muscular structure with emphasis on the relationship to diabetes, peripheral vascular disease and pathomechanical disease; make systemic as well as lower extremity diagnoses; conducts physical examination of any and all other areas of the body evidencing symptoms or conditions potentially contributing to disorders, diseases, injuries or symptoms of the foot; supplements examination by ordering or performing various laboratory tests, analyses and diagnostic procedures, including X-rays, which may be taken by the podiatry assistant under the registered podiatrist's supervision; interprets laboratory results and evaluates examination findings; refers patients to, or consults with, physicians for further case diagnoses or treatment; administers treatment to eliminate lesions, infections, contagious diseases affecting the foot and ankle and other symptomatic conditions of the foot and ankle causing pain or affecting ambulation; performs appropriate therapeutic surgical procedures; prescribes appropriate medication; instructs nurses and other assistants in treatment and care of patients; prescribes and supervises construction and maintenance of orthotic foot devices and fabricates special appliances to foot or in footgear to meet the needs of individual patients; applies appliances to foot or in footwear; initiates other podiatric procedures or services and advises patients on proper care of feet and nail prophylaxis; reviews and studies case history and progress of patient; consults with surgeons and residents in establishing a therapeutic program for the patient; records data or case history on medical records; and advises on kind and quality of podiatric medical supplies and equipment required.
4.02: Drug Dispensing and Prescribing
- In accordance with M.G.L. c. 94C, a podiatrist has the same rights in possessing, administering, dispensing and prescribing drugs as other practitioners and may prescribe, dispense and administer all reasonable substances which shall include but not be limited to all prescription drugs and controlled substances; or he or she may cause the same to be administered under his or her direction by a nurse.
- Prior to prescribing a hydrocodone-only extended release medication that is not in an abuse deterrent form, a licensee must
- Thoroughly assess the patient, including an evaluation of the patient’s risk factors, substance abuse history, presenting condition(s), current medication(s) and a check of the online Prescription Monitoring Program;
- Discuss the risks and benefits of the medication with the patient;
- Enter into a Pain Management Treatment Agreement with the patient that shall appropriately address drug screening, pill counts, safe storage and disposal and other requirements based on the patient’s diagnoses, treatment plan, and risk assessment;
- Supply a Letter of Medical Necessity as required by the Board of Registration in Pharmacy that includes the patient’s diagnoses and treatment plan, verifies that other pain management treatments have failed, indicates that a risk assessment was performed and that the licensee and the patient have entered into a Pain Management Treatment Agreement; and
- Document 249 CMR 4.02(2)(a)-(d) in the patient’s medical record.
- The purpose of 249 CMR 4.02(2) is to enhance the public health and welfare by promoting optimum therapeutic outcomes, avoiding patient injury and eliminating medication errors. Nothing in 249 CMR 4.02(2) shall alter the standard of care a licensee must use when prescribing any Schedule II, III or IV controlled substance.
4.03: Practice of Podiatric Medicine by Podiatric Medical Students
(1) A licensee may permit a podiatric medical student to practice podiatric medicine subject to the provisions of M.G.L. c. 112, § 16Aand B. The licensee's supervision of the podiatric medical student's activities must include the following requirements:
(a) The podiatric medical student must be identified to a patient as a podiatric medical student and each patient must be informed that the patient has a right to refuse examination or treatment by the podiatric medical student.
(b) The licensee must assure that the podiatric medical student practices podiatric medicine in accordance with acceptable podiatric medical standards of care.
(2) Only licensees and the other individuals mentioned in M.G.L. c. 94C may issue and sign for controlled substances when acting within the scope of their license.
4.04: The Podiatric Medical Record
The purpose of the podiatric medical record is to provide information to aid the registered podiatrist in the treatment of his patient. The licensee's medical record is not written for the purpose of third party payment review and should not be relied upon as a basis for a third party payor's denial of payment or as a basis for a third party payor's determinations regarding the medical necessity of services rendered. The record shall contain a record of significant treatment provided and findings made by the podiatrist. Should a third party payor require information regarding a patient's podiatric past or present needs beyond what is found in the medical record, the licensee may provide a brief written summary regarding that patient within 45 days of receiving that request in writing from the third party payor provided that no third party payor request more that 12 summaries in any one calendar year.
The licensee shall not be held responsible for the maintenance of any patient record(s) at a nursing home facility, hospital or any other location other than his own office.
4.05: Documentation Guidelines and Medical Necessity
(1) The Board shall set standards for the documentation of podiatric medical care and may make suggested documentation forms available to licensees. Documentation should be limited to that necessary for appropriate patient care in order to maximize the podiatrist's opportunity to provide direct patient care.
(2) A registered podiatrist shall determine the podiatric medical necessity of podiatric services. He or she shall follow guidelines established by the Board regarding the issue of medical necessity. The podiatric medical record shall not be the sole source of this determination but the podiatrist may also rely on other sources, including, but not limited to, records of other professionals.
4.06: Proper Foot Care in a Skilled Nursing Home Facility
(1) Independent practice in nursing home. A podiatrist attending patients in a skilled nursing home facility acts independently and is not under the supervision or control of any person employed by or practicing nursing or medicine at the nursing home facility. A licensed podiatrist is not required to obtain the approval or authorization of another physician or any other person before providing podiatry services in a skilled nursing home except from the patient or the patient's guardian who may request or refuse a podiatrist's services at any time. The direction and performance of a patient's podiatric care shall not fall within the purview of the nursing or medical staff at any level of the nursing home facility.
(2) Patient evaluation. A patient evaluation and management service, with treatment plan, detailing the type of care as well as its frequency, should be prescribed exclusively by the attending podiatrist. This is particularly appropriate for patients who will be receiving palliative foot care on a regular basis. [Board Form PD 1102 is approved and recommended for this service.] A reevaluation should be performed and treatment plan prescribed by the attending podiatrist approximately every 12 months or however often it is deemed necessary by the attending podiatrist for patients who receive palliative care.
(3) Documentation of palliation (trimming of nail and calvi) as well as treatment for onychomycosis, onychogryphosis and onychauxia should be minimized so as to allow the podiatrist the maximum opportunity to provide direct patient care. [Board Form PD1101 is approved and recommended for these services.]
(4) A patient who demonstrates any level of vascular insufficiency diagnosed by the attending podiatrist shall receive palliative foot care approximately every 60 days or however frequently the attending podiatrist deems that this service may be medically necessary. The podiatrist is the arbiter of podiatric medical necessity.
(5) A patient evaluation should be performed and treatment plan prescribed by the attending podiatrist at least every 12 months or more often if necessary. [Board Form PD1102 is approved and recommended for this evaluation and management service.]
4.07: Initial Patient History and Examination
(1) A registered podiatrist shall perform any and all patient examinations, including complete examinations, that are necessary for the effective identification and treatment of disorders, diseases, injuries or symptoms of the foot and ankle. Complete examinations, which are often necessary for the identification and assessment of systemic and localized conditions contributing to or causing disorders, diseases, injuries or symptoms of the foot and ankle, may encompass the evaluation of all organ systems or body parts.
(2) A registered podiatrist shall order the performance of any test or study necessary to establish a proper diagnosis. The level and comprehensiveness of the examination performed shall be determined by the attending podiatrist.
4.08: General Anesthesia
A licensee may perform surgery or treatment as set forth in M.G.L. c. 112, § 13 upon the human foot and ankle of a patient who is under anesthesia, which is not local provided that the anesthetic is administered by or under the direction of a qualified anesthesiologist.
4.09: Nitrous-Oxide-Oxygen Analgesia
A licensee may employ nitrous-oxide-oxygen analgesia in the practice of podiatric medicine provided, however, that the quantity of nitrous-oxide-oxygen administered does not produce loss of consciousness of the patient.
4.10: Acceptable Standards of Care
The Board shall determine standards of care for the delivery of podiatry through policy statements, which shall be made available to licensees.
249 CMR 4.00: M.G.L. c. 112, §§16, 17A, 19 and 61 through 65.