CMA (AAMA) In Sight
For Medical Assistants with an Eye for Excellence
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Independent Clinical Judgment in Chart Preparation
I recently received an email from a medical assistant in pathology requesting clarification on their scope of practice. Specifically, they wanted to know whether they could read a provider’s diagnoses and use that information to decide which documents they need to gather to prepare a patient’s chart.
Two of my Public Affairs articles published in Medical Assisting Today (formerly CMA Today),“What Tasks Are Delegable to—and Performable by—Medical Assistants?” part I and part II, contain legal principles generally applicable in all U.S. jurisdictions. Note the following excerpt from the handout that served as the source material for those articles:
7. General legal principles—
- It is not permissible for medical assistants to perform tasks that constitute the practice of medicine, or require the skill and knowledge of physicians or other licensed providers;
- It is not permissible for medical assistants to perform tasks that are restricted in state law to other health professionals—often licensed health professionals;
- It is not permissible for medical assistants to perform tasks that require the exercise of independent clinical judgment, and/or the making of clinical assessments, evaluations, or interpretations;
Deciding if further information is needed in a chart that is prepared in advance would seem to require some element of independent clinical judgment. If this is the case, a medical assistant should not be called upon to make this decision independently.
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Legal Eye
On Medical Assisting
Featured Posts
Independent Clinical Judgment in Chart Preparation
I recently received an email from a medical assistant in pathology requesting clarification on their scope of practice. Specifically, they wanted to know whether they could read a provider’s diagnoses and use that information to decide which documents they need to gather to prepare a patient’s chart.
Two of my Public Affairs articles published in Medical Assisting Today (formerly CMA Today),“What Tasks Are Delegable to—and Performable by—Medical Assistants?” part I and part II, contain legal principles generally applicable in all U.S. jurisdictions. Note the following excerpt from the handout that served as the source material for those articles:
7. General legal principles—
- It is not permissible for medical assistants to perform tasks that constitute the practice of medicine, or require the skill and knowledge of physicians or other licensed providers;
- It is not permissible for medical assistants to perform tasks that are restricted in state law to other health professionals—often licensed health professionals;
- It is not permissible for medical assistants to perform tasks that require the exercise of independent clinical judgment, and/or the making of clinical assessments, evaluations, or interpretations;
Deciding if further information is needed in a chart that is prepared in advance would seem to require some element of independent clinical judgment. If this is the case, a medical assistant should not be called upon to make this decision independently.
Independent Clinical Judgment in Chart Preparation
I recently received an email from a medical assistant in pathology requesting clarification on their scope of practice. Specifically, they wanted to know whether they could read a provider’s diagnoses and use that information to decide which documents they need to gather to prepare a patient’s chart.
Two of my Public Affairs articles published in Medical Assisting Today (formerly CMA Today),“What Tasks Are Delegable to—and Performable by—Medical Assistants?” part I and part II, contain legal principles generally applicable in all U.S. jurisdictions. Note the following excerpt from the handout that served as the source material for those articles:
7. General legal principles—
- It is not permissible for medical assistants to perform tasks that constitute the practice of medicine, or require the skill and knowledge of physicians or other licensed providers;
- It is not permissible for medical assistants to perform tasks that are restricted in state law to other health professionals—often licensed health professionals;
- It is not permissible for medical assistants to perform tasks that require the exercise of independent clinical judgment, and/or the making of clinical assessments, evaluations, or interpretations;
Deciding if further information is needed in a chart that is prepared in advance would seem to require some element of independent clinical judgment. If this is the case, a medical assistant should not be called upon to make this decision independently.
Full Archive >