MAs documenting injections for each other

sandyg68

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Cinncinatti
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Ugh, help! Our Medical Assistants have decided that since they are so busy it's ok to document services for each other to "help each other out" Such as...."injection of blah blah done by Jane Doe" but its documented by Susie Smith. This can't be acceptable, is it?? Of course, I haven't been able to find anything in writing as to exactly how an injection should be documented. Any help would be greatly appreciated!
 
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Bradenton, Florida
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MA documentation will primarily fall under your physician's signature and attestation to what happened with the patient on any given day. While there are certain specific guidelines that are clear for MAs this is probably more of an internal compliance prtocol and your physicians should be notified.

There are no other instances where physicians and other "qualifying" providers are permitted to sign or document for each other except where specificaly stated such as ROS, HPI, Vitals etc. Even those at the end of the day are signed off by the physician/provider.

This practice most certainly can put your practice at risk. A policy for all documenting providers in your practice should be developed.

Good Luck
 

kevbshields

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Louisville, KY
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Too, it seems that one MA is just acting as a scribe for another. Although I'm like you: cringing at the idea at first, it does seem like it would be allowable, just so long as the physician documents and attests on the note.
 
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Scribing is permitted for qualifying providers and there are specific CMS instructions on what that documentation should look like. This won't apply to MAs from a regulatory standpoint but might be a good documentation practice for the MAs to ensure medical record integrity.

Just think about all that is in your mind on any given day and then try to factually document something that you weren't even involved in. Leaves the practice and ultimately that attesting physician open for patient safety risks which can open a pandoras box in the event of a BME investigation, malpractice case, etc.

May seem small but imagine if the above came into play? It's simply not worth it to save 5 minutes of MA time. They are employed to save the providers time.

Good Luck!
 

sdeaton

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I agree it's mostly an internal policy issue. I personally don't like the idea and lean more toward the "finish what you start" premise. Our policy stipulates that the MA who starts the work (in this case injections) has to finish it and sign off on it.

And Nicole, you're right... MAs cannot be scribes for each other (at least not by CMS's definition)! Although, you might justify it in an emergency for the sake of record integrity. There's always that one MA who starts the process at 2:50 pm, knowing she's leaving at 3 pm and handing it off to someone else. I frown on that as well but, again, it's an internal policy issue.

Our physicians and PAs are required to attest the MA notes for injections and vaccines and I expect they would become quite vocal if they were to see multiple MA names on the same injection(s).
 
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