No state or federal regulations appear to prohibit a clinically trained staff member, such as a nurse or physician assistant (MA), from performing documentation and other clinical tasks without disconnecting from an EHR during a single encounter with a patient.
“There is a misunderstanding among some organizations that nurses and physician assistants need to log in and out of the EHR between performing tasks that would be considered clinical and those that are more office-focused. It’s not true,” said Christine Sinsky, MD, the AMA’s Vice President of Job Satisfaction.
The AMA is spreading this message through a series of “Debunking Regulatory Myths” articles that provide clarity to physicians and their care teams with the goal of reducing the administrative burdens that distract physicians from the delivery of patient care.
“Our main goal is to clear up the confusion around what the regulations require,” Dr. Sinsky said.
The AMA’s Regulatory Mystery Series is part of the AMA’s practice transformation efforts and provides resources for physicians and their care teams to reduce guesswork and administrative burdens so they can focus on streamlining clinical workflow processes, improving patient outcomes and increasing physician satisfaction.
This series includes a webpage dedicated to each regulatory myth, such as the one that physicians must re-document medical student entries in a patient’s EHR. In these articles, the myth is stated and debunked, and resources are provided to eliminate any lingering doubt that the myth is not true. More articles are added regularly.
It is common for MAs, nurses, and other healthcare professionals to participate in documentation and various clinical tasks while interacting with a patient under the advanced team care model. For example, they may take and record the patient’s vital signs, then record clinical notes while the physician meets with the patient.
In reviewing what states and the federal government require, the AMA found 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 tasks in a single patient encounter,” states the Regulatory Myth article.
He notes that the Centers for Medicare & Medicaid Services does not provide official guidance on using the documentation aid.
The Joint Commission also does not support or prohibit the use of documentation assistants. In a 2018 FAQ on documentation assistance, the commission encourages healthcare organizations to develop policies and procedures specific to documentation assistance and to create job descriptions that define the minimum qualification and the scope of work.
However, the American Health Informatics Management Association (AHIMA) – a non-regulatory professional association – advised in 2012 that MAs should log in and out of types of roles within the EHR when switching between documentation and other clinical tasks. AHIMA said there could be legal or other issues related to professional roles and responsibilities when a professional serves as scribe and clinical assistant during the same patient encounter.
Some organizations have created policies that a clinical assistant must log in and out of the EHR when switching tasks. DSEs can also have job-specific security access that limits the tasks that a particular type of user can perform while 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 that enable healthcare professionals to effectively use the EHR when encountering patients while working within the scope of their training and certification,” states the regulatory myth.
Dr. Sinsky also noted that “it’s usually helpful to ask to see the primary source of a rule when faced with a rule that doesn’t make sense or adds unnecessarily to the workload.”
Physicians and members of their care team are encouraged to submit questions about misinterpreted regulations that could divert their time from patients. Email the practice transformation team directly at [email protected].