No state or federal regulations appear to prohibit a clinically trained staff member—such as a nurse or medical assistant (MA)—from performing documentation and other clinical duties without logging out of an EHR during a single patient encounter.
“There is a misunderstanding among some organizations that nurses and medical assistants must sign in and out of the EHR between performing tasks that would be considered clinical and those that are more clerically oriented. This is not true,” said Christine Sinsky, MD, AMA vice president of professional satisfaction.
The AMA is spreading that message as part of a series of “Debunking Regulatory Myths” articles that provide clarification to physicians and their care teams in an effort to reduce the administrative burdens that divert doctors’ attention from the delivery of patient care.
“Our primary focus is to clarify confusion around what regulations require,” Dr. Sinsky said.
AMA’s debunking regulatory myths series is part of the AMA’s practice transformation efforts and provides physicians and their care teams with resources to reduce guesswork and administrative burdens so their focus can be on streamlining clinical workflow processes, improving patient outcomes and increasing physician satisfaction.
This series includes a webpage devoted to each regulatory myth, such as the one that physicians must re-document medical students’ entries in a patient’s EHR. In these articles, the myth is stated and debunked, and resources are provided to remove any lingering doubt that the myth isn’t true. More articles are being added regularly.
Regulations versus guidance
It’s common for MAs, nurses and other health professionals to take part in documentation and various clinical tasks while interacting with a patient under the advanced team-based care model. For example, they may take and record the patient’s vital signs and then document clinical notes while the physician meets with the patient.
In reviewing what the states and the federal government require, the AMA discovered that “to the best of our knowledge, no state or federal law or regulation prohibits a clinically trained staff member from performing both documentation and other clinical duties during a single patient encounter,” the regulatory myth item states.
It notes that the Centers for Medicare & Medicaid Services does not provide any official guidance on using documentation assistance.
The Joint Commission also does not support or prohibit the use of documentation assistants. In a 2018 FAQ about documentation assistance, The commission encourages health care organizations to develop policies and procedures specific to documentation assistance and create job descriptions that define minimum qualification and the scope of work.
However, the American Health Informatics Management Association (AHIMA)—a non-regulatory professional association—in 2012 advised that MAs should sign in and out of role types within the EHR when alternating between documentation and other clinical tasks. AHIMA said there could be legal or other issues revolving around job roles and responsibilities when a professional serves as scribe and clinical assistant during the same patient encounter.
Some organizations have created policies that say a clinical assistant must sign in and out of the EHR when they switch tasks. EHRs may also have job-specific security access that limits what tasks a particular type of user can complete when they are logged in. For example, a documentation assistant or scribe may not have the access they need in the EHR to perform clinical tasks.
“It is important for organizations to balance organizational security and access roles with policies and procedures allowing health care professionals to efficiently use the EHR during patient encounters while working within the scope of their training and certification,” the regulatory myth item states.
Dr. Sinsky also noted that “it is usually helpful to ask to see the primary source of a regulation when faced with a rule that doesn’t make sense or that unnecessarily adds to the workload.”
Send in your questions
Physicians and members of their care team are invited to submit their queries about misinterpreted regulations that might be diverting their time from patients. Email the practice transformation team directly at [email protected].
