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