Delegation to an Unlicensed Technician
A busy two-location practice employs three unlicensed ophthalmic technicians with an average of eight years' experience. The optometrist owner wants to reduce chair time. On Mondays and Wednesdays, when she covers the satellite office alone, she proposes that a senior technician: (1) perform non-contact tonometry and autorefraction; (2) instill proparacaine and tropicamide; (3) perform a preliminary slit-lamp examination and document 'normal anterior segment'; (4) finalize soft contact lens fit and release the lenses; and (5) sign the optometrist's name on spectacle prescriptions when the optometrist is at lunch. The technician is not certified or licensed. The optometrist asks whether this plan complies with New Hampshire law and Board rules. The practice has written protocols but no delegation policy. The technician would be alone with patients for 20 minutes at a time.
1. Which of the five proposed tasks may be delegated to the unlicensed technician, and which may not? Explain the governing principle.
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Tasks 1 and 2-non-contact tonometry, autorefraction, and instillation of diagnostic agents-are generally delegable to trained unlicensed assistants under appropriate supervision, because they are technical data-gathering steps. Task 3 is not delegable: a preliminary slit-lamp examination that includes interpretation and a 'normal' conclusion is the practice of optometry; the technician may position the patient or capture images, but the optometrist must examine and interpret. Task 4 is not delegable: finalizing a contact lens fit and releasing lenses requires professional judgment, including corneal evaluation, fit assessment, and patient education. Task 5 is not delegable: signing the optometrist's name to a spectacle prescription is prescribing and also raises a forgery and deception issue. The governing principle is that unlicensed staff may assist but may not diagnose, interpret, prescribe, or exercise independent professional judgment.
2. What supervision, documentation, and patient-communication safeguards should the practice adopt if it delegates the permissible tasks?
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Adopt a written delegation policy identifying each task, the required training, and the level of supervision. Verify competency initially and periodically. Require the technician to identify herself to patients as an assistant, not as a doctor. The optometrist should be physically present or immediately available as the Board rules require for the delegated tasks. Document who performed each test and what the optometrist reviewed. Do not use blanket standing orders for interpretation. Keep the technician's scope narrow and stop any task if the patient's condition is outside routine screening.
3. What are the consequences if the technician performs task 3 or task 5?
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If the technician performs task 3 or task 5, the technician may be engaged in unlicensed practice, and the optometrist may be aiding and abetting unlicensed practice and failing to supervise. That exposure includes Board discipline, civil liability, and insurance problems. A 'normal' notation by an unlicensed technician could also delay care if the optometrist relies on it without examining the patient. The practice should correct the policy, retrain staff, audit prior encounters, and self-report to the Board if a violation already occurred.