Special Report
MIEC Claims Alert
Number 32A
September 2006
Revised California version

Medical Assistants: An update on the scope and limits of training

• Training and certification requirements for medical assistants
• Supervision by PA, NP, or CNM
• Scope of practice
• Technical supportive services that a medical assistant cannot do
• MIEC’s recommendations
• In case you are wondering
• To reach MIEC
• Figure 1: Certifying agencies
• Figure 2: Sample Medical Assistant Certification form

According to the American Association of Medical Assistants (AAMA), the occupation of medical assistant (MA) is the fastest growing occupation in the country and is expected to grow much faster than the average occupation through 2012. Many physicians, clinics, and hospitals employ MAs to perform legally permissible technical support services. California law defines a “medical assistant” as a person who must be certified but is unlicensed; who performs basic administrative, clerical or technical support services for a licensed physician and surgeon, a podiatrist, group of physicians, a community clinic, or a healthcare services plan; who is at least 18 years old; and who has had at least the minimum number of hours of appropriate training pursuant to the standards established by the Medical Board of California’s Division of Licensing. The MA must obtain a certificate from a training institution or physician and surgeon or podiatrist indicating satisfactory completion of the required training. A copy of the certification shall be retained as a record by the MA's employer. Medical assistants are not physician assistants or nurses, and may not examine, diagnose or treat patients under any circumstances.

This Special Report Claims Alert reviews the role of the MA in a medical office practice. The laws that govern medical assistants are: California Business & Professions Code Sections 2052, 2069, 2070 and 2544; and California Code of Regulations, Title 16, Division 13, Chapter 3, Article 2, Section 1366. Additional information about MAs or their training and supervision may be obtained from: Division of Allied Health Professions, Medical Board of California, 1426 Howe Avenue, Suite 100, Sacramento, CA 95825, (916) 263-2344, or from the Board's web site: www.medbd.ca.gov.

Training and certification requirements for medical assistants

The California MA must receive training that assures the supervising physician and surgeon or podiatrist or instructor that the medical assistant is competent to perform the services at the appropriate standard of training. This training may take place either under the instruction of a licensed physician and surgeon or podiatrist, or under a registered nurse (RN), licensed practical or vocational nurse (LPN or LVN), physician assistant (PA) or a “qualified medical assistant” acting under the direction of a physician or podiatrist who will be responsible for the training of the MA candidate. Training may also take place in a secondary, postsecondary, or adult education program in a private or public school, institute or college. According to B&P Code §1206.5 and §2069(e), MAs may perform tests “waived” under CLIA (Clinical Laboratory Improvement Amendments of 1988), as long as they meet CLIA’s minimal requirements for MAs conducting tasks in physician office laboratories. An MA who works in a physician office may also draw blood upon specific authorization and under the supervision of a licensed physician and surgeon or podiatrist as long as the MA has received the training described below. As of April 9, 2006, an MA who is drawing blood outside a physician office or clinic must be a Certified Phlebotomy Technician under the regulations of the California Department of Health Services (DHS). For information on how to become a certified phlebotomy technician, visit the DHS web site at www.dhs.ca.gov/PS/LS/LFSB/html/phlebotomy.htm.

In order to administer medications by intramuscular, subcutaneous and intradermal injection, to perform skin tests by venipuncture or skin puncture for the purposes of withdrawing blood, an MA shall have completed the training below and demonstrated proficiency in each procedure: 

• Ten additional clock hours in administering injections and performing skin tests; and/or 
• Ten hours in venipuncture and skin puncture for the purpose of withdrawing blood;
• Satisfactory performance by the trainee of at least ten each of intramuscular, subcutaneous, and intradermal injections and ten skin tests; and/or
• At least ten venipunctures and ten skin punctures.  

Training to administer medication by inhalation must always be provided by a physician or respiratory care practitioner; trainees must complete at least ten hours of administering medication by inhalation, and must also include instruction and demonstration in:  

• Pertinent anatomy and physiology appropriate to the procedures;
• Choice of equipment;
• Proper technique, including sterile technique;
• Associated hazards and complications;
• Patient care following treatment or test;
• Emergency procedures; and
• California law and regulations for medical assistants.

The supervising physician or podiatrist must certify in writing that the prescribed training has been accomplished and observed, and must sign and retain a copy of this certification in the MA’s employment records. More than one task or service may be certified in a single document and separate certification may be made for subsequent training. See Figure 2. If training was received from a secondary, postsecondary or adult education program, the institution must issue a certificate indicating satisfactory completion of the required training.

Every medical assistant must receive instruction in the Centers for Disease Control’s (CDC) “Guideline for Infection Control in Health Care Personnel (1998),” and demonstrate that he or she understands the purpose and techniques of infection control. Physicians may obtain a copy of the guideline from the CDC’s web site: www.cdc.gov/ncidod/hip/GUIDE/InfectControl98.pdf.

Several institutions offer medi­cal assistant training and certifica­tion recognized by the Medical Board of California (MBC), including: the American Association of Medical Assistants (AAMA), the California Certifying Board for Medical Assistants (CMAA), the American Medical Technologists (AMT), and the Multiskilled Medical Certification Institute. See Figure 1. Certification by the AAMA and CMAA must be re­newed every five (5) years. Copies of the laws, regulations and cur­rent information regarding certify­ing agencies may be obtain­ed by contacting the Medical Board of California, Licensing Operations Section, at (916) 263-2393.

Supervision by Physician Assistants, Nurse Practitioners, or Nurse Midwives

B&P Code §2069 states that nurse practitioners, nurse midwives and physician assistants may supervise the work of the medical assistant when the physician is not physically present, but only in community or free clinics. The clinic’s supervising physician must provide written authorization delegating supervision of an MA. Such delegation must be within the standardized procedures or protocols, to occur when the supervising physician and surgeon is not on site, as long as the following apply:

• The nurse practitioner or nurse midwife is functioning pursuant to standardized procedure, as defined by protocol or B&P Code §2725; and 
• The physician assistant is providing services authorized by B&P Code §3502, and is approved to do so by the supervising physician and surgeon.

Scope of practice

According to California law, an MA in a private practice may perform basic administrative and clerical functions, administer medication by intradermal, subcutaneous, or intramuscular injection, perform venipuncture or skin puncture for the purpose of withdrawing blood, and other technical supportive services authorized and supervised by a licensed physician and surgeon, or podiatrist. A record must be made in the patient’s chart of each supportive service performed by the medical assistant, including the name of the physician who authorized performance of the task. The physician or podiatrist who authorizes the performance of supportive services by an MA must be physically present in the treatment facility during the completion of the tasks. The law also allows supervising physicians to provide written instructions to be followed by a medical assistant when performing tasks or support services. A physician assistant or registered nurse may assign a task authorized by a physician. [16 C.C.R. § 1366(a)(5)] Enactment of the new law allows flexibility for clinics in which a supervising physician cannot be present at all times during normal clinic business hours.

In California, an MA can:

• Administer medication orally, sublingually, topically, vaginally, rectally, or by single dose to a patient for immediate self-administration, or by inhalation if the medications are patient-specific and are routine for the patient. Prior to administration of medication, a licensed physician, podiatrist or another person authorized by law to do so shall verify the correct medication and dosage;
• Perform electrocardiogram, electroencephalogram, or plethysmography tests (except full body plethysmography);
• Apply and remove bandages and dressings, apply certain orthopedic appliances such as: knee immobilizers, envelope slings, orthotics and similar devices; remove casts, splints and other external devices; obtain impressions for orthotics, padding and custom molded shoes; select and adjust crutches and instruct patients in their use;
• Remove sutures or staples from superficial incisions or lacerations;
• Perform ear lavage to remove impacted cerumen;
• Collect (by non-invasive techniques) and preserve urine, sputum, semen, and stool specimens for testing;
• Assist patients in ambulation and transfers;
• Prepare patients for examinations or procedures by positioning, draping, shaving, and disinfecting treatment sites; and prepare a patient for gait analysis testing;
• Provide patient information and instructions as authorized by the physician or podiatrist;
• Collect and record patient data such as height, weight, vital signs, and basic information about presenting and previous conditions;
• Perform (but not interpret) simple medical office laboratory and screening tests;
• Cut nails of otherwise healthy patients; and
• Fit prescription lenses or use any optical device in connection with ocular exercises, visual training, or orthotics.

On authorization and with a licensed physician or optometrist physically present in the treatment facility, an MA in an ophthalmology practice may:

• Prepare patients for an exam;
• Collect patient data (including histories);
• Perform simple non-invasive testing of visual acuity, pupils, and ocular motility;
• Perform automated visual field testing;
• Perform ophthalmic photography and digital imaging, tonometry, lensometry;
• Perform non-subjective auto-refraction in connection with subjective refraction procedures performed by an ophthalmologist or optometrist;
• Administer cycloplegiacs, mydriatics, and topical anesthetics that are not controlled substances, for ophthalmic purposes; and
• Perform pachymetry, keratometry, A scans, B scans, and electrodiagnostic testing.

The above is not an exclusive itemization of the technical supportive services a medical assistant can perform. Additional information regarding MAs and their scope of training may be obtained by calling the Licensing Operations Section of the Medical Board of California at the phone number listed above.

Technical supportive services that a medical assistant cannot do

Medical assistants cannot:

• Independently diagnose or treat patients; 
• Perform arterial punctures;
• Start or discontinue IVs or insert urinary catheters;
• Administer physical therapy modalities (hot packs, diathermy, or exercise);
• Provide medical treatment, analyze or read test results, advise patients about their condition, or treatment regimen, make assessments or perform any kind of medical care decision making;
• Administer any anesthetic agent;
• Independently prescribe or refill medications;
• Practice physical therapy; (they may assist a physician by providing technical supportive services which utilize concepts of physical therapy); or
• Perform tests that involve the penetration of human tissues except for skin tests and drawing blood as provided by law.

MIEC’s recommendations 

The supervising physician or podiatrist is ultimately responsible and liable for the actions of MAs in his or her employ. For physicians who employ, or plan to hire a medical assistant, MIEC suggests the following:

• Ensure your medical assistants’ level of competency: make certain that adequate training was provided (or that adequate training is provided on site), that you are personally familiar with their knowledge and experience, and that you are confident they can satisfactorily complete the delegated tasks.
  
• Certify the in-practice training by documenting the type and duration of training: preserve the date and signature that verifies the certification and place the certificate in the MA’s employment file. A copy of the medical assistant’s certification from a teaching institution should also be placed in his or her employment file.
• Develop a written office policy that specifies the duties an MA can and cannot perform in your practice.
• Ensure that MAs document in patients' charts each technical supportive service performed, including: the medical assistant’s name, initials, or other identifier; the time and date; a description of the service performed; and the name of the physician and surgeon or podiatrist who authorized the service either directly or by a patient-specific standing order. (Example: 1/8/02, Per Dr. G’s order, trim­med Mrs. Q’s toenails (10) before assisting her return to her son-in-law in the reception area. SS, MA). 
• Consider MAs certified by formal training institutions as applicants for new positions to ensure that employees possess verifiable skills and training appropriate to medical assistants.
• Encourage medical assistants to participate in seminars, classes, in-service training or other means by which they can perfect their skills, stay current with relevant California laws, and learn ways to identify and prevent liability in an office practice.

In case you are wondering...

Does a medical assistant have to be licensed to practice in California?

No. MAs are not licensed, but do require certification by a physician employer or training institution. In California, the medical assistant is governed by the Medical Board of California, which sets the guide­lines, training and scope of train­ing for the profession. 

Does my MIEC insurance cover my medical assistants?

Yes. They will be covered under your policy for no additional charge, provided that they are performing within the scope of their training.

I refer to my medical assistant as “nurse” in the presence of patients; is that acceptable?

No. By calling your MA “nurse,” you are misleading your patients by implying that the MA has the training and licensure to function as a licensed vocational/practical nurse (LVN/LPN) or a registered nurse (RN). B&P Code §680 states that it is unlawful for persons to use the title of “nurse” in reference to himself or herself in any capacity, unless they are a registered nurse or a licensed vocational/practical nurse. The section also requires that a health care practitioner disclose, while working, his or her name and “practitioner’s license status” on a name tag with letters of at least 18-point type.  

Can a medical assistant prescribe or refill medications? 

No. Only a physician or someone licensed to practice medicine can independently prescribe or authorize the refill of medications. A medical assis­tant may pass on to a pharmacy a physician’s patient-specific authorization for the refill of a medication. Proper documentation of the transaction is important. When an MA documents refill information in the patient’s chart, the entry should indicate that the authorization is “per Dr. XX.”

Can MAs call in refills to a pharmacy?

Yes, according to the MBC, an MA may call in routine refills that are exact and have no changes in the dosage levels. The refill must be patient-specific and documented in the patient’s chart as a standing order. MAs may not call in new prescriptions or any prescriptions that have changes.

Can a medical assistant perform acupuncture? 

No. According to the Medical Board of California and Business & Professions Code §730.5(a) and (b), it is unprofessional conduct and a crime for a person who is not licensed pursuant to the Acupuncture Licensure Act to perform acupuncture.

Can MAs renew prescriptions based on protocols?

No, the MBC believes this would constitute the unlawful practice of medicine.

Can MAs draw blood?

Yes, MAs working in a “physician office laboratory “or clinic are authorized to perform venipuncture or skin puncture for the purpose of withdrawing blood upon specific authorization of the supervising physician or podiatrist, provided that the MA has been properly trained. The training must include the aforementioned ten hours of venipunctures and ten additional hours of practical training, and the satisfactory performance of at least ten venipunctures and ten skin punctures.

Are MAs allowed to inject collagen?

No. The injection of collagen or Botox does not fall within the medical assistant’s scope of practice. MAs are only authorized to inject “medications.”

I work in a community clinic. Can I leave the clinic while my medical assistant performs procedures?

Yes, under certain circumstances. Recently amended Business & Professions Code §2069 permits a supervising physician in a community clinic or free clinic only , at his or her discretion and in consultation with the nurse practitioner (NP), certified nurse-midwife (CNM), or physician assistant (PA), to provide written instructions for an MA to follow in the performance of tasks or supportive services. In the written instructions, the clinic doctor may delegate supervisory duties to the clinic’s nonphysician clinicians for tasks that an MA may perform when the doctor is on-site and/or off-site.

You may call MIEC’s Loss Prevention Department for answers to general professional liability questions about medical assistants. If you have patient-specific questions, please contact the Claims Department.

How to reach MIEC

We thank Thomas J. Donnelly, Esq., of Donnelly Nelson Depolo & Murray, LLP, Walnut Creek, California, for his review and assistance for this edition of Special Report Claims Alert.

Figure 1.