MA's Giving Medical Advice

Things Medical Assistants Can Not Do!

An area that can quickly lead to potential legal implications is when a medical assistant attempts to make independent health care assessments, or independently does triage, or gives medical, and health care advice to a patient without the doctor's knowledge.

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If Someone Asks...

It is not uncommon that a patient occasionally attempts to pull a medical assistant aside to ask their opinion, or advise about something that concerns their medical condition, medications, treatment regimen, or questions about instructions given by the doctor.

When this happens, even if asked in confidence, such concerns must ALWAYS be submitted back to the health care provider (doctor, nurse, practitioner), who is in charge of their care, to be addressed directly by them!!! Furthermore, any such concerns should be carefully charted and become a permanent part of the patient's medical record.

For Example:
Medical assistants are not allowed to make independent medical assessments (triage), or give medical advice at any time under any circumstances. Should a patient ask a medical assistant for a opinion, or advice directly related to medical issues, or medications, even if it seems like a casual conversation, the medical assistant should not take it lightly, nor make her own recommendations. The message should be put in writing, dated and initialed, and brought directly to the doctor's attention, along with the patient's medical chart, to follow up, and respond.

What the Medical Assistant Must Do to Follow Up

Next, it is well within a medical assistant's scope of practice to relay the doctor's message and instructions back to a patient, or skilled nursing facility staff (e.g. regarding a patient in a nursing home). To protect all involved, and for proper tracking, the message, once again, should be written out and initialed by the doctor.

Once again, this notebecomes official part of the patient's medical record, and should be filed directly into the patient's chart (i.e. NOT discarded, or left on the desk somewhere to get lost). Once executed, the medical assistant should briefly annotate the note with a date, and initial it, before filing it away.