Standing Orders and Supervision Requirements

I welcome further questions about my blog posts because addressing those questions allows me to dive deeper into a pertinent topic for medical assistants who wish to better understand their scope of practice.

For instance, in response to my blog post “Standing Orders from an Overseeing Provider,” I received the following question:

Does a standing order change the supervision requirements for medical assistants? For example, if our state law requires the delegating licensed provider to be on the premises when a medical assistant is performing venipuncture, is this supervision requirement changed by a standing order from the provider?

A standing order does not change the supervision requirement established by state law. The supervision requirements apply regardless of whether the licensed provider issues a standing order, verbal order, or written order. If this were not the case, a provider could circumvent supervision requirements by issuing standing orders instead of verbal orders.

The purpose of supervision requirements is patient protection.

Misuse of “CMA (AAMA)” and “CMA” Can Have Legal Consequences

Some medical assistants who do not hold the CMA (AAMA) credential awarded by the Certifying Board (CB) of the American Association of Medical Assistants (AAMA) incorrectly use the initialisms “CMA (AAMA)®” or “CMA” after their names. The AAMA has also received reports that some employers are permitting their medical assisting employees to misuse the “CMA (AAMA)” or “CMA” designations.

The AAMA owns Registration Number 4,510,101 issued by the United States Patent and Trademark Office (USPTO) for the certification mark “CMA (AAMA).”

The predecessor credential to the CMA (AAMA) was the CMA. Because of the decades of use of the CMA initialism in interstate commerce, the AAMA has common law rights in the “CMA” designation.

Consequently, using the initialisms “CMA (AAMA)®” or “CMA” or the phrase “Certified Medical Assistant” to describe a medical assistant who has not been awarded or has not maintained currency of the CMA (AAMA) credential from the Certifying Board of the AAMA is both incorrect and a matter of intellectual property law. Anyone who does so may be in jeopardy of legal sanctions.

The AAMA urges all medical assistants who are misusing the CMA (AAMA) or CMA initialisms, and all employers who are permitting their medical assisting employees to do so, to cease and desist immediately. The AAMA also requests that any instances of such misuse be brought to our attention.

I further explain the legality behind the AAMA’s claim to “CMA (AAMA)” variations in “Letters and the Law.”

The CMA (AAMA) Logo and Branding Usage Guide describes who has permission by the Certifying Board of the AAMA to use the CMA (AAMA) designation, initialism, and/or logo and lists common misunderstandings.

Medical Assistants Must Not Refer to Themselves as “Nurses”

Medical assistants must scrupulously avoid conveying the message that they are nursing personnel or members of any profession other than medical assisting.

It is unethical, illegal, and a disservice to the medical assisting profession for medical assistants to refer to themselves as “nurses,” “office nurses,” “doctors’ nurses,” or any other generic term that even remotely implies that medical assistants are nurses.

Review the supporting evidence within excerpts from the National Council of State Boards of Nursing NCSBN Model Act (2012) and several states’ nurse practice acts in the May/June 2019 Public Affairs article, “Medical Assistants Must Not Refer to Themselves as ‘Nurses,’” on the AAMA website.

Standing Orders from an Overseeing Provider

I receive the following question about standing orders fairly often, and it is a bit difficult to answer because state law seldom addresses it:

Our new office manager claims that it is illegal for medical assistants to perform tasks based on standing orders of our licensed providers. She states that only licensed professionals, such as registered nurses (RNs), are permitted to work under standing orders. Is this legally accurate?

Most state laws do not prohibit physicians, nurse practitioners, and physician assistants from assigning tasks to unlicensed allied health professionals such as medical assistants by means of standing orders.

However, the crucial issue is what tasks medical assistants may or may not be delegated by standing order.

It is my legal opinion that medical assistants are permitted to receive and execute standing orders from an overseeing/delegating provider as long as the following conditions are met:

1. The standing order is understood by the medical assistant.
2. The standing order is for a task that is delegable to medical assistants under the laws of the state, and the delegating provider is exercising the degree of supervision required by the laws of the state.
3. The standing order is either patient-specific or applicable to all patients without exception.
4. The standing order does not require the medical assistant to exercise independent clinical judgment or make clinical assessments, evaluations, or interpretations.

If you’d like to know more about your specific state laws, visit the State Scope of Practice Laws webpage on the AAMA website.

Distributing vs. Dispensing Drugs

If you’re a medical assistant with questions about handing sample medications or drugs to patients, consider the following situation a CMA (AAMA) in Texas brought to my attention:

I am a CMA (AAMA) employed in a large, multispecialty clinic. I received an order from one of our licensed providers to distribute packets of sample medications to a patient. Is this legal in my state [Texas]? I thought only pharmacists and their staff were permitted to dispense medications.

To answer the question accurately, we have to define some terms. Note the following definitions from the Texas Pharmacy Act:

Sec. 551.003. DEFINITIONS. In Chapters 551-566:

(1) “Administer” means to directly apply a prescription drug to the body of a patient by any means, including injection, inhalation, or ingestion, …

…

(16) “Dispense” means to prepare, package, compound, or label, in the course of professional practice, a prescription drug or device for delivery to an ultimate user or the user ‘s agent under a practitioner ‘s lawful order.

(17) “Distribute” means to deliver a prescription drug or device other than by administering or dispensing.

Also, note the following from the Texas Occupations Code:

§157.002.General Delegation of Administration and Provision of Dangerous Drugs

(a) In this section:

(1) “Administering” means the direct application of a drug to the body of a patient by injection, inhalation, ingestion, or any other means.

(2) “Provision” means the supply of one or more unit doses of a drug, medicine, or dangerous drug.

(b) A physician may delegate to any qualified and properly trained person acting under the physician’s supervision the act of administering or providing dangerous drugs in the physician’s office, as ordered by the physician, that are used or required to meet the immediate needs of the physician’s patients. The administration or provision of the dangerous drugs must be performed in compliance with laws relating to the practice of medicine and state and federal laws relating to those dangerous drugs.

According to these definitions, “distributing” a drug is not the same as “dispensing” a drug.

Under the laws of most every state, physicians are permitted to distribute/provide sample medications to their patients. (This is also generally the case with nurse practitioners and physician assistants, although the laws vary from state to state.)

The laws of many states explicitly or implicitly permit physicians to assign to knowledgeable and competent medical assistants working under their direct/on-site supervision the distributing or providing of sample medications to patients of the physician.

In the scenario described, the CMA (AAMA) is being asked by a delegating licensed provider to distribute/provide sample medications to patients, not to dispense medications.

It is my legal opinion that, if there is a likelihood of significant harm to a patient if the sample medication is selected or distributed improperly, the delegating provider must verify the identity and the dosage of the sample medication before it is distributed to the patient by the medical assistant.