1.3 Physician Delegation of Laser, Light, RF & Plasma Devices (WAC 246-919-605 / 606)
Key Takeaways
WAC 246-919-605 defines laser, light, radiofrequency, and plasma (LLRP) devices as FDA prescription devices that topically penetrate skin and alter tissue, and treats their use as the practice of medicine.
Before authorizing LLRP treatment, the physician must take a history, examine, diagnose, recommend treatment, obtain informed consent that discloses a nonphysician may operate the device, and prepare a medical record.
A delegating physician needs a written office protocol, a quality assurance program, and must be on the immediate premises during each patient's initial treatment.
During temporary physician absences, a local back-up physician must agree in writing, be reachable by phone, and be able to see the patient within 60 minutes.
WAC 246-919-606 lets physicians delegate injections and other non-LLRP prescription cosmetic devices only to physician assistants, registered nurses, and licensed practical nurses.
Where the Medical Rules Fit
RCW 18.16.020 says a master esthetician's use of medical devices must comply with any law or rule requiring delegation or supervision. For physicians in Washington, those rules are in chapter 246-919 WAC, adopted by the Washington Medical Commission. Two sections matter most:
- WAC 246-919-605, use of laser, light, radiofrequency, and plasma devices as applied to the skin; and
- WAC 246-919-606, nonsurgical medical cosmetic procedures.
Physician assistants have a parallel rule, WAC 246-918-125, for using or delegating LLRP devices.
What Counts as an LLRP Device
Under WAC 246-919-605(1), LLRP devices are medical devices that:
- use a laser, noncoherent light, intense pulsed light, radiofrequency, or plasma to topically penetrate skin and alter human tissue; and
- are classified by the FDA as prescription devices.
Because these devices penetrate and alter tissue, their use is the practice of medicine under RCW 18.71.011. The rule lists the complications it is designed to prevent: visual impairment, blindness, inflammation, burns, scarring, hypopigmentation, and hyperpigmentation. Using an energy device to penetrate or alter tissue for any other purpose is surgery and falls outside the rule.
The Physician's Duties
Before a physician authorizes treatment with an LLRP device, WAC 246-919-605(6) requires the physician to:
- take a history;
- perform an appropriate physical examination;
- make an appropriate diagnosis;
- recommend appropriate treatment;
- obtain the patient's informed consent, including telling the patient that a nonphysician may operate the device;
- provide instructions for emergency and follow-up care; and
- prepare an appropriate medical record.
No matter who performs the treatment, the physician is ultimately responsible for the patient's safety and must make sure every treatment is documented in the patient's medical record. The physician must also ensure the facility has a quality assurance program that includes:
- a way to identify complications and untoward effects and find their cause;
- a way to review whether supervised professionals follow the written protocols;
- a way to monitor treatment quality;
- a way to feed quality findings back into future protocols and supervision; and
- ongoing training for treating professionals.
Conditions for Delegating to a Master Esthetician
WAC 246-919-605(10) allows a qualified physician to delegate an LLRP procedure to a properly trained and licensed professional whose license and scope allow it, only if all of these conditions are met:
| Condition | What it means in the treatment room |
|---|---|
| No surgery | The treatment cannot involve surgery as understood in medicine. |
| Within the delegate's scope | For a master esthetician, RCW 18.16.020 supplies that scope. |
| Not on the globe of the eye | The device may not be used on the eyeball itself. |
| Written office protocol | Identifies the physician; states activities, decision criteria, and plans; sets patient selection criteria; lists devices and settings; explains operation and maintenance; describes care for common complications, serious injury, and emergencies; and sets documentation and feedback to the physician. |
| Delegate training | At minimum: application techniques for each device, cutaneous medicine, indications and contraindications, pre- and post-procedure care, potential complications, and infectious disease control. |
| No independent medical judgment | The delegate follows the written protocol only. |
| Initial treatment | The delegating physician must be on the immediate premises during each patient's initial treatment and able to treat complications. The delegate may finish the initial treatment if the physician is called away for an emergency. |
| Temporary absences | Existing patients with an established plan may continue if a local back-up physician agrees in writing to cover, is reachable by phone, and can see the patient within 60 minutes. Absences must be brief and intermittent, never an ongoing arrangement. |
Injections and Other Prescription Cosmetic Devices
WAC 246-919-606 covers nonsurgical medical cosmetic procedures: injecting a medication or substance for cosmetic purposes, or using a prescription device for cosmetic purposes. It does not cover surgery, LLRP devices (which stay under 605), nonprescription devices, intravenous therapy, or a licensed health professional working within that professional's own scope.
Key points:
- A physician may delegate these procedures only to a properly trained physician assistant, registered nurse, or licensed practical nurse. Master estheticians are not on that list.
- Each patient signs a consent form listing foreseeable side effects and complications and naming the delegate and the delegate's license. Delegates must wear a name tag or similar identification.
- If the medication or substance is not FDA-approved for that purpose, the physician must be on site for the entire procedure. If it is approved for that purpose, the physician must be reachable by phone and able to respond within 30 minutes.
- The physician must have equipment inspected, calibrated, and certified as safe according to the manufacturer's specifications, and may not sell or give a prescription device to someone without prescriptive authority.
What This Means on the Exam
The NIC outline asks you to "apply knowledge of practicing in a medical setting" and to recognize issues outside your scope. In Washington terms:
- A master esthetician may operate a prescription laser, IPL, RF, or plasma device only under a physician's delegation that meets every 605 condition.
- The physician, not the esthetician, examines, diagnoses, and approves the treatment plan.
- Injections and prescription cosmetic devices covered by 606 are delegated only to PAs, RNs, and LPNs.
- When something unexpected happens, follow the written protocol's complication plan and notify the physician.
Note
DOL's own guidance repeats the key point: master estheticians may use prescription devices only under the authority of a licensed physician. For other health-professional routes, DOL refers laser technicians to the Department of Health.
Under WAC 246-919-605, where must the delegating physician be during a patient's initial treatment with a delegated LLRP device?
On the immediate premises and able to treat complications
Available by video within 24 hours
Reachable by phone within 30 minutes
Anywhere, if a back-up physician is listed in the protocol
An established laser patient returns while the delegating physician is briefly away. What does WAC 246-919-605 require for treatment to continue?
Advance approval from the Department of Licensing for each physician absence
A registered nurse on the premises who can answer the esthetician's protocol questions
Written permission from the patient, signed again before every treatment session
A local back-up physician available by phone who can see the patient within 60 minutes
Under WAC 246-919-606, to whom may a physician delegate cosmetic injections?
Licensed estheticians and master estheticians working inside a medical spa
Any trained staff member, provided each delegate wears a name tag
Physician assistants, registered nurses, and licensed practical nurses
Any master esthetician who has documented device and injection training
Sections you finish are checked off in the contents.