[Skip to Content]
[Skip to Content Landing]

Are Clinical Support Staff Required to Log Out of EHR Between Documentation?

Learning Objectives
1. Describe the myth or issue that impacts physicians and their care teams
2. Explain how clinical support staff should document role-specific activities
0.25 Credit CME
Abstract

In advanced team-based care models, clinical assistants, such as medical assistants (MA) and nurses, often perform both documentation and other clinical tasks in the course of patient care. For example, a nurse may obtain and record a patient's vital signs and chief complaint, then shift to documenting clinical notes in partnership with the physician. In the course of the visit, the nurse or MA may switch frequently between these different tasks. There thus exists a myth that clinical support staff, such as nurses and medical assistants, are required to log out of the EHR, then log in again when switching task types for the purpose of clarifying role-specific activity in the event of an audit.

The Myth

Clinical support staff, such as nurses and medical assistants, are required to log out of the electronic health record (EHR), then log in again when switching task types for the purpose of clarifying role-specific activity in the event of an audit.

In advanced team-based care models, clinical assistants, such as medical assistants (MA) and nurses, often perform both documentation and other clinical tasks in the course of patient care. For example, a nurse may obtain and record a patient's vital signs and chief complaint, then shift to documenting clinical notes in partnership with the physician. In the course of the visit, the nurse or MA may switch frequently between these different tasks.

Debunking the Myth

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 Centers for Medicare & Medicaid Services (CMS) does not provide official guidance on the use of documentation assistance. However, job-specific security access in electronic health records (EHRs), typically set by organizational policies, may limit what tasks can be completed when a particular type of user is logged in. For example, someone designated as a documentation assistant or scribe may not have access to perform clinical tasks in the EHR. 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/or certification.

Regulatory Clarification

  1. In 2012 the non-regulatory professional association American Health Informatics Management Association (AHIMA) issued guidance that MAs should sign in and out of role types within the EHR when alternating between documentation and other clinical tasks. AHIMA advises there may be legal or other issues regarding job roles and responsibilities when an individual fills the role of scribe and clinical assistant simultaneously during the same encounter.1 This guidance caused some organizations to create internal policies requiring clinical assistants to sign in and out of the EHR when task switching. In some situations, these policies may not be practical or necessary.

  2. The Joint Commission (TJC) does not support or prohibit the use of documentation assistants.2

  3. In July 2018, TJC published an FAQ concerning documentation assistance after reviewing relevant literature and visiting organizations utilizing clinical support staff to help with EHR documentation.2 The FAQ re-defines what a documentation assistant or scribe is and what they do, and provides guidance on basic competency expectations. Importantly, it encourages health care organizations to develop policies and procedures specific to documentation assistance, along with job descriptions defining minimum qualifications and scope of work.2

Resources

AMA Steps Forward Success Story: https://edhub.ama-assn.org/steps-forward/module/2768111

AMA Team-Based Care STEPS Forward Toolkit: https://edhub.ama-assn.org/steps-forward/module/2702513

AMA Team Documentation STEPS Forward Toolkit: https://edhub.ama-assn.org/steps-forward/module/2702598

Hopkins K, Sinsky C. Team-Based Care: Saving Time and Improving Efficiency. Fam Pract Manag. 2014 Nov/Dec, pp 23-29. https://www.aafp.org/fpm/2014/1100/p23.html

Sign in to take quiz and track your certificates

To help improve the quality of its educational content and meet applicable education accreditation requirements, the content provider will receive record of your participation and responses to this activity.

The AMA Debunking Medical Practice Regulatory Myths series provides physicians and their care teams with regulatory clarification to streamline clinical workflow processes and improve patient outcomes. Learn more

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.25 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.25 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.25 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;

0.25 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and

0.25 CME points in the American Board of Surgery’s (ABS) Continuing Certification program.

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

References:
1.
The Joint Commission.  Standards FAQs.  Documentation Assistance Provided by Scribes. 2021. https://www.jointcommission.org/standards/standard-faqs/ambulatory/record-of-care-treatment-and-services-rc/000002210/Google Scholar
2.
AHIMA.  Using Medical Scribes in a Physician Practice.  Journal of AHIMA83, no.11 ( November 2012): 64-69 [expanded online version]. https://library.ahima.org/doc?oid=106220.Google Scholar
3.
Hopkins  K, Sinsky  C.  Team-Based Care: Saving Time and Improving Efficiency.  Fam Pract Manag. 2014 Nov/Dec, pp 23-29. https://www.aafp.org/fpm/2014/1100/p23.htmlGoogle Scholar
Close
Close
Close
Close

Name Your Search

Save Search
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close