This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.
Computerized provider order entry (CPOE) is a process of electronic entry of medical practitioner instructions for the treatment of patients under the physician’s care. Physicians use CPOE to increase efficiency and reduce errors by submitting orders in the EHR.
The myth
Only physicians can pend, or enter, orders into the EHR—and a nurse, certified medical assistant (MA) or other non-credentialed staff can't pend or send orders in the EHR as requested by the physician.
Debunking the myth
All members of the care team assisting with documentation, including nurses, credentialed medical assistants (MAs), or non-credentialed staff members can enter orders in the EHR, as requested by the physician (e.g., conveyed verbally or through written checklist), in a manner consistent with state and institutional policies. Additionally, there is no Medicare EHR incentive program that requires CPOE.
Regulatory clarification
The Centers for Medicare & Medicaid Services eliminated the previously required CPOE and CDS objectives and associated measures1. Similarly, The Joint Commission has eliminated previous prohibitions on documentation assistants entering orders on behalf of physicians.2
References
- CMS Fact Sheet, CMS Finalizes Hospital Outpatient Prospective Payment Changes for 2017, November 2016
- Documentation Assistance Provided by Scribes. Perspectives Newsletter – The Official Newsletter of The Joint Commission, 38 (8). The Joint Commission, August 2018
Debunking Regulatory Myths overview
Visit the overview page for information on additional myths.
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AMA seeks to aid physicians and care teams by helping them understand medical regulatory requirements. Help us help you—submit a myth you'd like clarification on.
Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues.
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