The AMA Debunks Myths Around Clinical Support Staff Documentation Inside EHRs

March 27, 2023
Clinical Support Staff Documentation Inside EHRs

There is a myth that clinical support staff such as nurses and medical assistants, are required to log out of the Electronic Health Record (EHR), then log in again when switching task types for the purpose of clarifying role-specific activity in the event of an audit. For example, a nurse may obtain and record a patient’s vital signs and chief complaint, then shift to documenting clinical notes in partnership with the physician. In the course of the visit, the nurse or MA may switch frequently between these different tasks. The incorrect belief being that there needs to be a method of knowing exactly who performed each aspect of clinical documentation. This is one of several myths that the American Medical Association (AMA) has been debunking in a project called “Debunking Regulatory Myths.”

The AMA has concluded, “To the best of our knowledge, no state or federal law or regulation prohibits a clinically trained staff member from performing both documentation and other clinical duties during a single patient encounter… However, job-specific security access in electronic health records (EHRs), typically set by organizational policies, may limit what tasks can be completed when a particular type of user is logged in.”

You can read the entire article below:


Caroline Fife, MD

Dr. Fife is Co-Founder and Chief Medical Officer of Intellicure, Executive Director of the US Wound Registry, and Editor of Today’s Wound Clinic.

Subscribe to the Intellicure Blog!

Submit the form below to receive email alerts when Intellicure publishes a new blog post! This information will not be shared.

Follow Intellicure

You May Also Like …