The COVID-19 pandemic has made unprecedented human resource demands on the American health care system. In particular, health professionals with varying levels and types of professional education and credentials have been called to treat COVID-19 patients in hospitals and other acute care settings.
 
Although medical assistants are employed primarily in ambulatory care during normal times, they have more recently been asked to work in the acute care environment because of the enormous need to deploy skilled and dedicated health professionals to where they are most needed. Indeed, executive orders of state governors have reflected the necessity of giving knowledgeable and competent medical assistants more responsibility.
 
Because medical assistants have not typically worked in acute care settings, inevitable questions about the legal parameters of medical assisting scope of practice have arisen. In many cases, answering these questions is difficult because state laws have been written to address medical assistants’ scope of practice within only the typical ambulatory setting. The following are examples of the types of questions I have been receiving and the answers I provided.

State examples

New Hampshire

I received the following question from a New Hampshire medical assistant (email, March 30, 2020):

My employer is sending me to the hospital to work as an aide under the direction of nurses, given the COVID-19 crisis. Is this going to get me into trouble? Can they do this?

Medical assistants are classified as unlicensed assistive personnel under the rules of the New Hampshire Board of Nursing:

“Unlicensed assistive personnel” means an unlicensed individual who functions in a complementary role to the licensed RN [registered nurse] or LPN [licensed practical nurse] in providing patient care.1

Medical assistants, therefore, may be delegated tasks by nurses in accordance with the following excerpt from the New Hampshire Board of Nursing code:

(a) The following licensees shall have the authority pursuant to RSA 326-B to delegate nursing-related activities:

(1) Any currently licensed RN or APRN [advanced practice registered nurse] when practicing registered nursing; and

(2) Any currently licensed LPN when practicing practical nursing directed by a licensed APRN, RN, dentist or physician.

(b) For nursing-related tasks involving assistance with or the administration of medication, the following persons shall be eligible to be delegatees:

(1) Any currently licensed RN and APRN;

(2) Any currently licensed LPN, only when:

a. The method of medication administration is not intravenous; or

b. The method of medication administration is intravenous and the LPN is in compliance with Nur 604.01 (b) and (c);

(3) Unlicensed assistive personnel who have competency to perform the specific task to be delegated [emphasis added.]2

Arizona

I received the following question from a clinical education specialist and professional development coordinator in Arizona (email, March 31, 2020):

Is a hospital able to utilize [medical assistants] during these emergent times in the inpatient world with strictly defined roles, such as taking vital signs and documenting in the EMR [electronic medical record] under strict LIP [licensed independent provider] orders? As we face critical staffing, our hospital is moving toward “all hands on deck.” I am aware that [medical assistants] work strictly and directly under the supervision of a LIP; however, if specific orders are given to [medical assistants] to take vitals and document them within the inpatient world, are there laws forbidding medical assistants to be utilized in this way?

To answer these questions, note the following excerpts from the Arizona Board of Nursing rules:

R4-19-101. Definitions

“Unlicensed assistive personnel” or “UAP” means a CNA [certified nursing assistant] or any other unlicensed person, regardless of title, to whom nursing tasks are delegated. …

R4-19-402. Standards Related to Registered Nurse Scope of Practice

D. An RN assigns and delegates nursing activities. The RN shall:

1. Assign nursing care within the RN scope of practice to other RNs;

2. Assign nursing care to an LPN within the LPN scope of practice based on the RN’s assessment of the client and the LPN’s ability;

3. Supervise, monitor, and evaluate the care assigned to an LPN; and

4. Delegate nursing tasks to UAPs. In maintaining accountability for the delegation, an RN shall ensure that the:

a. UAP has the education, legal authority, and demonstrated competency to perform the delegated task;

b. Tasks delegated are consistent with the UAP’s job description and can be safely performed according to clear, exact, and unchanging directions;

c. Results of the task are reasonably predictable;

d. Task does not require assessment, interpretation, or independent decision making during its performance or at completion;

e. Selected client and circumstances of the delegation are such that delegation of the task poses minimal risk to the client and the consequences of performing the task improperly are not life-threatening;

f. RN provides clear directions and guidelines regarding the delegated task or, for routine tasks on stable clients, verifies that the UAP follows each written facility policy or procedure when performing the delegated task;

g. RN provides supervision and feedback to the UAP; and

h. RN observes and communicates the outcomes of the delegated task.3

Based on the above, my legal opinion is that Arizona nursing law allows medical assistants to work as unlicensed assistive personnel under RN authority and supervision as long as all the requirements in the above excerpt are met.

Oregon

A similar question was asked by an Oregon director of clinic operations and provider relations (email, March 26, 2020):

Because of the COVID-19 pandemic, are medical assistants permitted by Oregon law to perform clinical tasks similar to those of a certified nursing assistant (CNA) in inpatient settings?

A medical assistant is an unregulated assistive person under the Oregon nursing law. The provisions in an Oregon State Board of Nursing interpretive statement shed considerable light on what RNs are authorized to assign to unregulated assistive persons:

When the RN is practicing with a care team member whose role or position within the organization does not require health-related licensure or certification by the state of Oregon, that care team member is recognized by the RN as an unregulated employee or UAP [unregulated assistive person] staff member. When the activity to be performed is within the UAP’s position description, and there is documented education and current competency validation of the UAP having been done by the organization employing both the RN and the UAP staff member, then that activity is work that the UAP is already authorized to perform and thus may be assigned to the UAP by the RN. UAP staff members include, but are not limited to, those in the following organizational job positions: Medical Assistant …, Certified Medical Assistant, Registered Medical Assistant …, Emergency Department Technician, Labor and Delivery Technician, etc.4

Consequently, medical assistants’ scope of practice under RN supervision is determined by (1) the organization’s position description for “unregulated assistive person” and (2) whether “there is documented education and current competency validation of the UAP having been done by the organization employing both the RN and the UAP staff member.”4

Additional resources

Although the above examples make up only a fraction of U.S. states, they serve as a guide for understanding other state laws. Check with the AAMA State Scope of Practice Laws webpage5 to find key scope of practice materials for all states.

Questions about medical assisting scope of practice in acute care settings may be directed to Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org.