delegation, Scope of Practice

Permissible Delegation to Montana Medical Assistants

I recently received the following appeal from a licensed practical nurse working in Montana:

I’m requesting something in writing that states that CMAs (AAMA) can still administer immunizations. The verbiage that my bosses are reading has [caused them to change] what our medical assistants can and can’t do. I depend on [medical assistants] being able to give shots (i.e., immunizations) when working with me.

For documentation related to this issue, go to the State Scope of Practice Laws webpage on the AAMA website to find the medical assisting laws of all states, including Montana.

Note the following from the Montana Code Annotated (MCA):

37-3-104. Medical assistants — guidelines. (1) The board shall adopt guidelines by administrative rule for:

(a) the performance of administrative and clinical tasks by a medical assistant that are allowed to be delegated by a physician, physician assistant, or podiatrist, including the administration of medications; and

(b) the level of physician, physician assistant, or podiatrist supervision required for a medical assistant when performing specified administrative and clinical tasks delegated by a physician, physician assistant, or podiatrist. However, the board shall adopt a rule requiring onsite supervision of a medical assistant by a physician, physician assistant, or podiatrist for invasive procedures, administration of medication, or allergy testing. [Italics added.]

Further, note the following from the Administrative Rules of Montana (ARM):

24.156.401    MEDICAL ASSISTANT – DELEGATION AND SUPERVISION

(1) A health care provider authorized by 37-3-104, MCA, may delegate administrative and clinical tasks which are within the delegating health care provider’s scope of practice to medical assistants who:

(a) work in the delegating health care provider’s office under the general supervision of the delegating health care provider; and

(3) A health care provider delegating administrative and/or clinical tasks to a medical assistant shall:

(c) personally provide onsite direct supervision as defined by ARM 24.156.501 to a medical assistant to whom the health care provider has delegated:

(i) injections other than immunizations;

(ii) invasive procedures;

(iii) conscious sedation monitoring;

(iv) allergy testing;

(v) intravenous administration of blood products; or

(vi) intravenous administration of medication [Italics added.]

The definition for direct supervision is in ARM “Definitions”:

(7) “Direct supervision” means the supervising physician is:

(a) physically present in the same building as the person under supervision; or

(b) in sufficiently close proximity to the person under supervision to be quickly available to the person under supervision. [Italics added.]

Given this language from the Montana statutes and regulations, my legal opinion is that Montana law permits physicians to delegate to medical assistants—who have the knowledge and competence outlined in the Montana rules—the administration of immunizations under the physician’s general supervision. My opinion is also that Montana law requires the delegating physician to be exercising direct supervision when medical assistants are performing the following tasks outlined in ARM:

(ii) invasive procedures;

(iii) conscious sedation monitoring;

(iv) allergy testing;

(v) intravenous administration of blood products; or

(vi) intravenous administration of medication

delegation, On the Job, Scope of Practice

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.

delegation, On the Job, Scope of Practice

Delegation from Varying Licensed Providers

Determining whether you are successfully working within your legal scope of practice as a medical assistant requires recognizing some situational nuances, especially on the matter of delegation. The following demonstrates one such instance:

I work in an outpatient practice setting. At times, I work under the authority and supervision of a physician. At other times, I work under the authority of a nurse practitioner or a physician assistant. I have been informed that my legal scope of practice is the same regardless of which licensed provider is assigning tasks to me. Is this correct?

Not necessarily. Under the laws of most states, the medical assistants’ scope of practice is determined by the practice act and regulations of the delegating provider.

For example, the nurse practice act and the regulations and policies of the state’s board of nursing determine which tasks nurses (including advanced practice registered nurses [APRNs], such as nurse practitioners) are permitted to delegate to medical assistants.

On the other hand, the medical practice act and the regulations and policies of the state’s board of medical examiners delineate which duties physicians are allowed to assign to medical assistants. And physician assistant delegation authority is established by other state statutes, regulations, and policies.

There are legal nuances that must be taken into consideration. Some states permit nurse practitioners to work autonomously and without a collaborative practice agreement with a physician. In these states the delegation authority of autonomous nurse practitioners is determined by the nurse practice act and the rules of the board of nursing.

However, nurse practitioners in an independent-practice state may choose to work under physician authority and supervision, and physicians may assign nurse practitioners to oversee medical assistants who are performing tasks delegated to them by a physician. In such a case, both the medical practice act and the nurse practice act may have a bearing on the scope of practice of a medical assistant.

delegation, On the Job, Scope of Practice

Comments to the Montana Board of Medical Examiners

In the effort to protect patients in Montana from substandard medical assisting services, the Montana Society of Medical Assistants (MSMA) and the American Association of Medical Assistants (AAMA) wrote to the Montana Board of Medical Examiners on the proposed New Rule I “Medical Assistant—Delegation and Supervision.” Read the comments as well as an excerpt from the proposed new rules in the latest Public Affairs article. Access “Comments to the Montana Board of Medical Examiners” in the September/October 2018 issue of CMA Today on the AAMA website.

medication aide, Scope of Practice

Scope of Practice in Correctional Facilities

The versatility of CMAs (AAMA) is being reflected in the questions I am starting to receive about the scope of practice for medical assistants working in correctional facilities.

If the CMAs (AAMA) are working under direct provider supervision in a clinic within a correctional facility, the standard laws for medical assisting scope of practice apply.  However, if a CMA (AAMA) is functioning as a medication aide and distributing medications under registered nurse supervision (similar to what occurs in a skilled nursing facility or an assisted living facility), the medical assistant would have to meet the state requirements and register with the appropriate state agency as a medication aide.