Only Select Professionals May Legally Use “Nurse” As a Title

I recently received the following significant question about permissible titles:

Recently [someone] was hired in my company, and she is a CMA (AAMA).

Can she call herself a “nurse”? She insisted on getting a name badge that identifies her as a nurse. … I remember being taught we cannot. I found and read the June 2019 article you wrote saying we cannot.

As stated in the 2019 Public Affairs article, the laws in all American jurisdictions continue to forbid anyone—other than registered nurses (RN), licensed practical nurses (LPN), or licensed vocational nurses (LVN)—from calling themself a nurse.

Note the following from a 2019 Advisory Opinion issued by the Kentucky Board of Nursing:

KRS 314.031(1) states: “It shall be unlawful for any person to call or hold [themself] out as or use the title of nurse or to practice or offer to practice as a nurse unless licensed or privileged under the provisions of this chapter.”

Age Requirements for Ohio Medical Assistants

I recently received the following question from an Ohio educator regarding age restrictions for medical assistants:

 Can you tell me if there is any legal implication that [a medical assistant] who has completed a high-school training program [but] is not yet 18 might [be unable] to work as a medical assistant until they turn 18? 

The medical assisting laws of all states, including Ohio, are available on the “State Scope of Practice Laws” webpage. 

Notably, Ohio law does not require medical assistants to be at least 18 years of age to work as a medical assistant. 

However, a few states ​(such as California) do require medical assistants to be at least 18 in order to work as a medical assistant. 

The Delegation of Off-Site Blood Draws in WA

In-home patient visits necessitated by COVID-19 raise questions about the scope of practice for medical assistants working off-site. For example, I received the following email from a Washington chief of primary care regarding delegation during off-site visits:

We are instituting programs where medical assistants see patients in their homes and help set them up for video visits [in response to COVID-19]. Many of our providers are requesting [laboratory work] from these appointments. [Can] a phlebotomy-certified medical assistant draw blood if a provider is not in attendance and the patient is doing a video visit with the provider?

To answer this question, note the following excerpt from the Washington statutes, especially the italicized, underlined language at the end of this excerpt:

RCW 18.360.010

Definitions. (Effective until July 1, 2022.)

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) “Administer” means the retrieval of medication, and its application to a patient, as authorized in RCW 18.360.050.

(2) “Delegation” means direct authorization granted by a licensed health care practitioner to a medical assistant to perform the functions authorized in this chapter which fall within the scope of practice of the health care provider and the training and experience of the medical assistant.

(3) “Department” means the department of health.

(4) “Forensic phlebotomist” means a police officer, law enforcement officer, or employee of a correctional facility or detention facility, who is certified under this chapter and meets any additional training and proficiency standards of [their] employer to collect a venous blood sample for forensic testing pursuant to a search warrant, a waiver of the warrant requirement, or exigent circumstances.

(5) “Health care practitioner” means:

(a) A physician licensed under chapter 18.71 RCW;

(b) An osteopathic physician and surgeon licensed under chapter 18.57 RCW; or

(c) Acting within the scope of their respective licensure, a podiatric physician and surgeon licensed under chapter 18.22 RCW, a registered nurse or advanced registered nurse practitioner licensed under chapter 18.79 RCW, a naturopath licensed under chapter 18.36A RCW, a physician assistant licensed under chapter 18.71A RCW, an osteopathic physician assistant licensed under chapter 18.57A RCW, or an optometrist licensed under chapter 18.53 RCW.

(6) “Medical assistant-certified” means a person certified under RCW 18.360.040 who assists a health care practitioner with patient care, executes administrative and clinical procedures, and performs functions as provided in RCW 18.360.050 under the supervision of the health care practitioner.

(7) “Medical assistant-hemodialysis technician” means a person certified under RCW 18.360.040 who performs hemodialysis and other functions pursuant to RCW 18.360.050 under the supervision of a health care practitioner.

(8) “Medical assistant-phlebotomist” means a person certified under RCW 18.360.040 who performs capillary, venous, and arterial invasive procedures for blood withdrawal and other functions pursuant to RCW 18.360.050 under the supervision of a health care practitioner.

(9) “Medical assistant-registered” means a person registered under RCW 18.360.040 who, pursuant to an endorsement by a health care practitioner, clinic, or group practice, assists a health care practitioner with patient care, executes administrative and clinical procedures, and performs functions as provided in RCW 18.360.050 under the supervision of the health care practitioner.

(10) “Secretary” means the secretary of the department of health.

(11) “Supervision” means supervision of procedures permitted pursuant to this chapter by a health care practitioner who is physically present and is immediately available in the facility. The health care practitioner does not need to be present during procedures to withdraw blood, but must be immediately available [emphasis added].

My legal opinion is that the above language permits licensed providers to assign to medical assistants who are off-site in the homes of patients the performing of phlebotomy/venipuncture as long as the delegating/overseeing provider is immediately available, such as by video or audio means.

Permissible Delegation of Influenza Vaccination Administration in Michigan

Medical assistants are well-positioned to assist with vaccinations, but legal considerations may vary depending on state law. For example, I recently received the following question regarding when a medical assistant in Michigan can be delegated the administration of influenza vaccinations:

I have two medical assistants in our occupational health/employee health clinic who operate under a provider and can give injections. We are part of a hospital that is across the street from our clinic. Can the two medical assistants give influenza shots in the hospital setting without our provider actually on-site?

To answer this question, note the following from the Michigan Public Health Code, which is posted in the Michigan subsection of the State Scope of Practice Laws webpage on the AAMA website:

333.16215 Delegation of acts, tasks, or functions to licensed or unlicensed individual; supervision; rules; immunity; third party reimbursement or worker’s compensation benefits.

Sec. 16215.

(1) Subject to subsections (2) to (6), a licensee who holds a license other than a health profession subfield license may delegate to a licensed or unlicensed individual who is otherwise qualified by education, training, or experience the performance of selected acts, tasks, or functions where the acts, tasks, or functions fall within the scope of practice of the licensee’s profession and will be performed under the licensee’s supervision. A licensee shall not delegate an act, task, or function under this section if the act, task, or function, under standards of acceptable and prevailing practice, requires the level of education, skill, and judgment required of the licensee under this article. [Italics added.]

In this excerpt, the definition of “licensee” includes a licensed physician. Medical assistants are considered unlicensed individuals under Michigan law.

Furthermore, the definition of “supervision” in this part of the Michigan law is as follows:

(2) “Supervision”, except as otherwise provided in this article, means the overseeing of or participation in the work of another individual by a health professional licensed under this article in circumstances where at least all of the following conditions exist:

(a) The continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional.

(b) The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual, to review records, and to further educate the supervised individual in the performance of the individual’s functions.

Therefore, my legal opinion is that Michigan law permits physicians to delegate the administration of influenza vaccinations to knowledgeable and competent unlicensed individuals such as medical assistants as long as the delegating physician is accessible to the medical assistants by radio, telephone, or telecommunication.

CDC Affirms Medical Assistants’ Role in Telehealth

In a recent guidance on how to expand access to health care during the COVID-19 pandemic, the Centers for Disease Control and Prevention affirmed that medical assistants and other health care professionals are permitted to interact with patients by several means. Note the following from this guidance:

Telehealth Modalities

Several telehealth modalities allow [health care personnel] and patients to connect using technology to deliver health care:

Synchronous: This includes real-time telephone or live audio-video interaction typically with a patient using a smartphone, tablet, or computer.

In some cases, peripheral medical equipment (e.g., digital stethoscopes, otoscopes, ultrasounds) can be used by another HCP (e.g., nurse, medical assistant [italics added]) physically with the patient, while the consulting medical provider conducts a remote evaluation [emphasis added in red].

Asynchronous: This includes “store and forward” technology where messages, images, or data are collected at one point in time and interpreted or responded to later. Patient portals can facilitate this type of communication between provider and patient through secure messaging.

Remote patient monitoring: This allows direct transmission of a patient’s clinical measurements from a distance (may or may not be in real time) to their healthcare [sic.] provider.

Additionally, in its Telehealth Implementation Playbook, the American Medical Association listed ways in which medical assistants can use telehealth to help their overseeing physician/provider:

MEDICAL ASSISTANT (MA) OR PATIENT CARE TECH (PCT)

Be familiar with the conditions and situations that are appropriate for a telehealth visit

Educate patients on telehealth expectations

Support patient troubleshooting related to platform pre-visit and during visit

Let [the] doctor know when a patient has “checked in” for a telehealth appointment (if platform does not include this feature)