medication reconciliation

Permissible Medication Reconciliation by Medical Assistants

I recently received a question from a medical assistant who had developed a PowerPoint for her employer about medication reconciliation. While her managers approved her work, she was concerned that a second PowerPoint created by another employer group contradicted some of the points she made about medication reconciliation.

In response, the medical assistant asked me whether it is correct—as she wrote in her PowerPoint—to say that medical assistants can note in the medical record the fact that a patient is no longer taking a medication.

Note the following excerpt from the handout I used during my presentation this summer for the American Academy of Ambulatory Care Nursing. This provides a general legal rule about the scope of practice of medical assistants in all states:

General legal principles—

  • 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;5
  • Medical assistants must not be delegated (and must not perform) any tasks for which they are not sufficiently knowledgeable and competent

I believe the confusion between the two PowerPoints is based on a different understanding of terms. The medical assistant’s position is that medical assistants are permitted to remove a medication from a patient’s list of medications based on the patient’s statement only to inform the provider that, for example, another provider has discontinued a medication. The current provider can then determine whether they agree with the other provider about the discontinuation of the medication or whether they think that the patient should resume taking the medication.

I suspect that the other employer group’s PowerPoint slides define the removal of medication as a decision by the provider to remove medications from the list of medications the patient should be taking. A decision about what medications a patient should be taking can only be made by a licensed provider.

Note the following excerpt from my opinion letter on medication reconciliation (note a related Legal Eye blog post):

[Medication reconciliation, as defined by the Joint Commission,] “ … comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.”

It is my legal opinion that knowledgeable and competent medical assistants can be assigned steps 1, 2, and 3 as long as step 2 entails compiling a list of prescribed medications from the prescription orders of providers. However, step 4 requires the exercising of independent professional judgment and the making of clinical assessments. Therefore, in my judgment, medical assistants cannot be assigned step 4. In regard to step 5, medical assistants can communicate verbatim new lists of medications as specifically approved by the overseeing/delegating provider and only when the provider directs the medical assistant to do so.

Step 3 above involves comparing the list of medications in the patient’s record with the patient’s statement about the discontinuation of medications. My legal opinion is that a medical assistant is permitted to perform this task, delete any medications from the list based on the patient’s statement only for the purpose of informing the licensed provider, and submit the list for evaluation by the provider. The provider must decide to accept the discontinuation of a medication or to reinstate it in the patient’s list of medications.

Therefore, I agree with the medical assistant who reached out to me that medical assistants are permitted by federal and Texas law to eliminate a medication from a list for the purpose of informing the provider. In such situations, medical assistants do not make any clinical decisions based on the comparison of the previous and current medication lists, which is the responsibility of the licensed provider.

delegation, On the Job, Scope of Practice

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.

Uncategorized

Favorable Report from the Connecticut Department of Public Health

In November I described the continuing scope of practice issues that exist for medical assistants in Connecticut. I also detailed my efforts in concert with the Connecticut Society of Medical Assistants (CSMA) to correct these issues and see legislation passed that allows professionally educated and suitably credentialed medical assistants to administer medication under physician supervision.

In response to our letter (the body of which will be available in the upcoming March/April issue of CMA Today), the Connecticut Department of Public Health formed a scope of practice review committee to examine the request. The committee consisted of representatives from a number of organizations—not just the AAMA and CSMA, but the Connecticut Hospital Association, the Connecticut State Medical Society, and the Connecticut Association of Optometrists, among others. All information provided in the scope of practice request was reviewed by the committee, after which a report was issued. While this report makes no recommendations as to potential legislation, there are a number of positives to be taken from it.

First, the report acknowledges the ability and education of medical assistants:

“Literature and other information reviewed and evaluated by the scope of practice review committee demonstrated that certified medical assistants are educated and trained to administer medication under the direct supervision of a licensed physician. Accredited education and training programs that lead to certification as a medical assistant … include coursework and clinical training in pharmacology and medication administration.”

The report goes on to acknowledge that certification programs like those offered by the Certifying Board of the AAMA provide powerful evidence that medical assistants possess the knowledge necessary for medication administration, and that such certification programs could potentially be used as a standard in Connecticut.

In addition, the report also states that allowing medical assistants to administer medication should allow physicians and nurses to see more patients and focus on clinical care, as our letter argues.

The report goes on to confirm that all the information provided by the AAMA and CSMA allowed the committee to thoroughly address any quality and safety risks surrounding this issue. In addition, the report recommends that a number of terms must be clarified in any proposed legislation:

  • “Physician”
  • “Certified medical assistant”
  • “Outpatient setting”
  • “Direct supervision”

In short, the report discussed necessary steps that should be taken in the event that our recommended legislation is proposed. The report itself is over 15 pages long, but nonetheless includes some very encouraging reports about the progress of our work!

As always, I will keep you informed of any further developments in this matter.

Scope of Practice

Success in Nevada State Senate!

Good afternoon, everyone! I hope your summers are going splendidly. I have some fantastic news to share with you all. The Nevada State Senate recently passed into law the bill allowing medical assistants to administer medications under the supervision of a physician. You’ll remember that Nevada State Society President Carol Cohen and I worked on such matters earlier this spring (See “Right-to-practice Issues in Nevada“). We were hopeful that the bill would pass the Senate, and that hope proved justified. You can review the final text of the bill at http://www.leg.state.nv.us/Session/76th2011/Bills/SB/SB294_EN.pdf. Thank you again for all of your support!