CME: Delegation to medical assistants: Risks, rewards, and safety strategies

Objectives

Upon completion of this educational activity, the learner should be able to:

• discuss appropriate roles and scope for medical assistants working in outpatient physician practice;
• identify potential areas of medical liability risk when supervising medical assistants; and
• apply risk management strategies to increase patient safety when supervising and delegating to medical assistants.

Course author

Tanya Babitch is the Assistant Vice President of Risk Management at TMLT.

Disclosure

Tanya Babitch has no relevant financial relationship(s) with ineligible companies to disclose. TMLT staff, planners, and reviewers have no relevant financial relationship(s) with ineligible companies to disclose.

Target audience

This 1-hour activity is intended for physicians of all specialties who are interested in learning more about strategies for appropriate supervision of medical assistants within their practice.

CME credit statement

The Texas Medical Liability Trust is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Texas Medical Liability Trust designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Ethics credit statement

This course has been designated by TMLT for 1 credit in medical ethics and/or professional responsibility.

Test

To receive CME credit, physicians should complete the test questions that follow the activity. A passing score of 70% or better earns the physician 1 CME credit.

Pricing

The following fee will be charged when accessing this CME course online at http://tmlt.inreachce.com.

Policyholders: $10

Non-policyholders: $75

Instructions

CME test and evaluation forms must be completed online. After reading the article, go to http://tmlt.inreachce.com. Log in using your myPortal account information to take the course. Follow the online instructions to complete the forms and download your certificate. To create a myPortal account, go to www.tmlt.org, click the log in button, and follow the on-screen instructions.

Release/review date

This activity is released on September 1, 2025, and will expire on September 1, 2028. Please note that this CME activity does not meet TMLT’s discount criteria. Physicians completing this CME activity will not receive a premium discount.

Introduction

Medical assistants (MAs) have become an integral part of the health care team in both inpatient and outpatient settings. The use of MAs in outpatient physician practices has become widespread, with almost 90 percent of primary care practices employing MAs. (1) The majority of MAs (56 percent) work in outpatient physician practices. Employment of MAs is estimated to grow 15 percent from 2023 to 2033. (2)
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With many new MAs entering the workplace, it is not uncommon for training to occur onsite after employment by a physician practice. MAs’ educational opportunities vary widely, from an associate’s degree and certification to no formal training. Certification or formal education by an accredited institution is not required for MAs working in some states, including Texas, but some states do have training or educational requirements. In 2023, data from the American Association of Medical Assistants (AAMA) and the Bureau of Labor Statistics indicated that approximately 10 percent of MAs were certified by such organizations as the AAMA, the National Healthcareer Association (NHA), and the American Medical Technologists (AMT).(3) 
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In many practice scenarios, even if an MA has formal education and/or certification, a significant portion of their training occurs on the job. The quality of this on-the-job training, along with appropriate selection of delegated tasks, detailed protocols, ongoing monitoring, and effective communication within the health care team, can ensure that MAs have clear guidance on how to function well within your practice.
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For physicians, there is potential liability for the actions of MAs —  as with other non-physician members of the health care team. Liability may arise from allegations of vicarious liability or negligent supervision. These claims may involve allegations that the physician practice (as the employer) was responsible for acts of their employees, or that the physician should have been more active in supervision of the care provider. In both these scenarios, a medical practice’s prior implementation of appropriate delegation protocols, training, and observation of the health care team can prevent claims, mitigate liability, and increase defensibility in the event of a claim.

Scope of practice

Outside of state-specific regulations, an MA’s scope of practice may, to a certain extent, be determined by the physician. This scope may be dependent on the skill level, certification, and experience of the MA.
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MAs may not exercise independent medical judgment or perform independent medical assessments, but may perform delegated tasks that do not require clinical judgment. Some of the duties commonly performed by MAs include administrative and clinical tasks, such as:

• scheduling appointments;
• escorting patients to the exam room;
• conducting patient history interviews;
• taking and recording vital signs;
• preparing patients for examinations;
• entering information into the medical record;
• transmitting prescriptions to pharmacies;
• communicating with patients via telephone or EMR portal (with protocols to determine the acuity of the patient’s concern);
• assisting with medical examinations/surgical procedures;
• setting up/cleaning patient rooms;
• maintaining inventory;
• restocking supplies in patient rooms;
• performing venipuncture;
• collecting and preparing laboratory specimens and performing basic laboratory tests;
• administering immunizations or other medications as directed;
• removing sutures and changing dressings;
• performing electrocardiograms (with specialized training);
• notifying patients of laboratory results (as directed by protocol);
• assisting with patient education and instruction; and (4)
• tracking laboratory and diagnostic test orders.

Delegation laws and rules

Appropriate delegation by physicians to staff (including MAs) is critical. Rules regarding who can delegate duties to MAs vary from state to state. For more information on rules and regulations regarding delegation and scope of practice, the American Association of Medical Assistants (AAMA) offers a listing by state of applicable laws. Physicians are encouraged to review their state’s specific laws and rules to ensure compliance.
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For example, in most outpatient settings in Texas, MAs may not perform medical acts without delegated authority from a physician. If working in a practice setting that also employs nurses, registered nurses (RNs) may delegate certain nursing tasks, such as taking and documenting vital signs, to MAs. (5) Tasks that require independent medical or nursing judgment should not be delegated to MAs, but Texas law does allow a certain amount of latitude to physicians determining what tasks are delegable to their MAs.
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The Texas Occupations Code states that a “physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate if, in the opinion of the delegating physician”, the act:

• can be properly and safely performed by the person to whom the medical act is delegated;
• is performed in its customary manner; and
• is not in violation of any other statute.
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Importantly, the “delegating physician remains responsible for the medical acts of the person performing the delegated medical acts”. (6)
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Physicians must determine what acts can be performed safely by MAs within their practices. Again, the MA’s training, experience, and skillset must be considered before determining what acts may be appropriately delegated. MAs working in your practice may be delegated different tasks depending on these factors. If so, be sure that the protocols that outline who can do what are clearly delineated.
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If you practice outside of Texas, please check the AAMA listing and your state laws for further guidance.

Proceed with caution and planning

A review of TMLT’s medical liability claims involving the actions of MAs reveals certain “danger” areas. As physicians are burdened with more tasks, it may be tempting to allow MAs to take on more responsibilities and expand the scope of their duties within the practice.
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Additionally, there may be instances when a trusted MA with a long-term relationship with the physician may be encouraged to take on tasks that are outside of their role or to manage tasks independently. Taking steps to monitor duties and ensure that MAs are not working outside their scope is essential.
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Common areas of risk seen in medical liability claims include lack of training and supervision, MAs performing duties outside of their scope, and communications with patients without appropriate protocols or guidance. Allowing or encouraging MAs to perform tasks outside of their scope can be a risk to your patients, your practice, and you. Taking appropriate steps at the beginning of an MA’s employment, and re-assessing regularly, can help clarify roles and reduce risks.

Risk management and safety strategies for team success

Training, observation, and revisiting skills checklist regularly

Establishing good training protocols when a new MA joins your practice can set them up for success. The following steps may help you realistically assess an MA’s strengths and weaknesses and identify what training is needed before your MA begins participating in patient care.

• When a new MA joins the practice, provide them with a detailed job description, practice policies and procedures, and applicable protocols. Give them time to review, ask questions, and share any concerns. Encourage open dialogue and let your team know that there are no “stupid questions.” Once their review is complete, obtain their signature and date to indicate their acknowledgment.
• Maintain documentation of any certifications, education, or training your staff has participated in, whether externally or within your practice. If MAs are recertified or participating in ongoing training, continue to collect and maintain these records.
• During onboarding, realistically assess your MA’s training, experience, and skill level before determining readiness to perform assigned tasks. If additional training is needed, allocate time and personnel to perform the training.
• While performing initial training, conduct an observation period during which you watch the MA performing essential tasks. Document your observations, such as dates, number of patients/cases, task(s) observed X number of times, task(s) performed successfully or additional training needed, etc. Use a skills checklist to record their competency in each task. Skills checklists may include tasks such as taking vital signs, obtaining a patient history, reviewing and updating medications, documenting in the EMR, administering and documenting vaccines, and other duties.
• Take time to regularly reassess the role of individual MAs within your practice. Revisit the skills checklist biannually, annually or more frequently if needed.
• When delegating new tasks, consider first whether they are within the MA’s scope, and whether your MA has any prior experience performing that task. If not, ensure training is thorough and observe and monitor new tasks as you would for a new MA.  

Transparency regarding MAs working in the practice

Clarity within your practice and with your patients about the role of MAs will help set reasonable expectations. In addition, protocols that demonstrate patient awareness of who is involved in their care and that no one was represented dishonestly, can protect you and your staff in the event of a claim.

• Do not refer to MAs as nurses. Train front desk personnel or staff taking phone calls to refer to everyone in the practice by name and appropriate designation. For example, staff should not say “Let me transfer you to Dr. X’s nurse” when transferring a call to an MA. If a patient asks to speak to “Dr. X’s nurse,” they can be gently corrected by stating, “Let me transfer you to Dr. X’s medical assistant, Beth” (or something similar). 
• The use of name tags or visible identification for all staff in your practice is recommended. It helps patients develop relationships with your team and clarifies staff roles.
• MA entries and signature in the record should include their role, i.e. “Beth Smith, MA”, and any certification if applicable; “Beth Smith, CMA.”

Delegation and protocols

The physician should develop clear delegation protocols regarding tasks performed by MAs. These protocols should include detailed instructions on performing tasks, so it is clear that MAs are not expected — or allowed — to exercise clinical judgment. Protocols should be reviewed and updated regularly or as needed, and the delegating physician(s) and MAs should review and acknowledge via signature and date when changes are made. Protocols may include guidance on many (or all) of the MA duties. Outlined below are areas of risk that have been identified in medical liability claims.

Vaccine and medication administration

If MAs in your practice administer vaccines or other medications, your protocols should include specifics about how to appropriately perform and document these tasks. Points to cover may include how to safely draw and administer injections, infection control measures, distribution and documentation of Vaccine Information Statements (VIS), and precautions for patient safety such as pre-injection questions/screening and post-injection patient observation.

Responding to patient calls or questions

It’s important to remember that triage is not within the scope of an MA’s duties. In fact, only physicians, advanced practice providers (APPs), or RNs can perform triage that involves independent clinical judgment. In many practices, MAs may be the “front line” in managing patient calls and messages. If this is the case, consider these steps to reduce your risk.

• If taking patient calls or reviewing EMR portal messages, MAs should have clear written protocols developed by the physician(s) to guide their actions. A protocol may be as simple as, “Any clinical question is forwarded to Dr. X or APRN X.”
• If physicians allow MAs to respond directly to inquiries from patients, protocols should be more detailed, comprehensive, and problem-specific. For example, if a patient contacts the practice about certain symptoms they are experiencing, protocols should address whether the call should be escalated to a physician or APP, and what symptoms are considered emergent, urgent, or necessitate referral to the emergency department or same-day appointment.
• When applicable, MAs should be supplied with specific screening questions to ask the patient to determine next steps (escalation or patient instructions). These screening questions should not require independent analysis or clinical judgment.
• MAs should be encouraged to consult with a physician, APP, or RN if they are unsure about a response.

Medication refill management

Medication refill requests from patients must be managed with great care. Inappropriate approvals of medication refills without “guardrails” (protocols) could result in significant patient harm.
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In many practices, refills may be reviewed and approved only by a physician or APP. Some practices allow refills to be filled by other clinical staff with written protocols, while others allow a clinical team member to do the initial screening and forward approved refills to the physician for final sign-off before sending to the pharmacy. Ultimately, physicians must decide what they are comfortable delegating.
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State regulations should also be considered. Certain states, such as California, have specific laws regarding the MA’s role in refill management. (7) Texas law does not address the role of MAs in refill management, but does require that physicians designate and retain a list of the personnel who are allowed to transmit refills to pharmacies. (8)
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If you allow MAs or any staff member in your practice to play a role in refill management, proceed with caution and develop appropriate protocols. Protocols to guide refill management may include the following.

• ‍A limited list of medications that may be refilled by MAs or another staff member. Be conservative when determining which medications are appropriate for this list.‍
• A list of the types of medications that may NOT be refilled by MAs or another staff member. These might include controlled substances, antibiotics, and other medications that have significant risks or contraindications.‍
• A list of mandatory questions to ask patients. These questions should be determined by the physician. A patient answering “yes” to any of these questions would necessitate review by the physician before any further action is taken. Example questions may include:
  
  • Are you taking any other prescribed or over-the-counter medications or supplements that are not on the list we went over?
  • Do you have any issues or questions about the medication you’re requesting?
  • Is there a possibility you are pregnant? (if applicable to medication)
  • Are you requesting a change of dosage?‍
• Additional parameters determined by the physician(s), such as:
  
  • number of refills allowed;
  • whether the patient has had appropriate lab testing within the required timeframe;
  • whether the refill is within an acceptable timeline from last appointment; and
  • whether a scheduled follow-up appointment is required to process the refill request.
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Err on the side of caution. Allowing staff members to manage portions of the refill process should be done only after careful consideration. If questions arise or a staff member is uncertain about a refill request, they should be trained/instructed to consult a physician.

Communication and team engagement

Physicians, as leaders of the team, must encourage staff to communicate any concerns or questions openly and without fear. Communication failure has been identified in multiple studies as a significant contributor to patient injury and medical liability. The Joint Commission identifies “communication error among the most common attributable causes of sentinel events.” (9) Open and clear communication may be the most critical factor when working as a part of a health care team.

• As discussed above, develop written, acknowledged protocols that are readily available to all for review when needed. Regularly assess these protocols as a team. If questions or issues arise, meet to review together in a group discussion. While emailing and messaging has become a primary communication method, in-person meetings may achieve goals more promptly and with clarity for all.
• When possible, engage MAs in making decisions regarding protocols and processes that they will be expected to perform. For example, if MAs manage the process for tracking and following lab or other diagnostic orders, review your EMR system’s capabilities together to determine how best to use them. Once processes have been developed, check in with the team after a week or two to see how well the process is working. If issues need to be addressed, ask for their ideas to help resolve them. People are much more likely to follow a protocol or process if they have been engaged and involved in its development.
• Hold regular, scheduled staff meetings to discuss any issues affecting the practice or your patients. Ask that staff share their questions, concerns, or ideas in these meetings. If concerned about time, ask for agenda items before the meeting.
• Reiterate to your team that you want to hear from them, and that open communication will not be punished. It is preferable to know if your staff needs additional training or has questions about a process before issues arise.
• Give MAs ongoing, constructive feedback. Do not ignore problems that are identified; address any issues promptly.

In summary

The medical assistants you work with every day are a vital part of the patient care team. Working closely with them to establish good protocols and communication enhances both the safety of your patients and your practice. By prioritizing the development of workflows and protocols and encouraging effective communication and team engagement, physicians can support MAs and other staff to work within their professional boundaries.

Taking these steps enhances patient safety and leads to high-functioning care teams. A proactive approach toward working with your MAs and clinical team helps to minimize risk of liability and fosters a culture of accountability and continuous quality improvement.

Case study: Failure to see patient for follow up

Presentation

A 51-year-old man came to the emergency department (ED) of a regional medical center at 2:55 p.m. on Thursday. The patient had been seen at his employer’s health clinic for mild chest pain, right arm pain, left arm pain, and thigh pain. Before that visit, the patient had played one hour of tennis. His employer’s clinic called his family physician who instructed the patient to go to the ED immediately.
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In the ED, the patient said that he took no medications, had no prior surgeries, and had borderline high blood pressure. He played tennis daily for exercise, did not smoke, but drank beer.

Physician action

According to the ED triage nurse, the patient reported chest tight­ness since 10 a.m. and joint discomfort. The discomfort worsened with activity. His initial vital signs were blood pressure, 151/101 mm Hg; pulse, 106 bpm; respirations, 22. He was placed on a monitor and pulse oximeter and was noted to be in no acute distress.
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An emergency medicine (EM) physician examined the patient at 3:25 p.m. He noted the patient was in mild distress but was otherwise asymptomatic. When specifically questioned by the physician, the patient refused to use the term “chest tightness” for what he experienced, instead calling it a “chest sensation.” He told the physi­cian his symptoms had started the day before, and that he had a physical one month earlier.
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The EM physician completed a thorough physical exam, and the results were normal. He ordered a monitor, chest X-ray, pulse oximeter, oxygen, IV access, and lab work including CBC, UA, Chem7, cardiac enzymes, and PT/PTT. He ordered two baby as­pirin to be given. The physician’s recollection is that the patient’s chest “sensation” did not occur during the exam.
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The patient’s lab results and chest X-ray were within normal limits. An EKG revealed a normal sinus rhythm with nonspecific T-wave changes laterally. Because the pa­tient did not have chest pain during the ED visit and his symptoms started more than 24 hours earlier with no enzyme elevation, the physician did not recommend admission.
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At 5:15 p.m., the EM physician called the patient’s family physician to schedule a follow-up appointment. Though the details of this conversation were not documented, an appointment was scheduled for 11:30 a.m. Friday, the next day.
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The patient was discharged at 5:30 p.m. He was instructed to follow up with his family physician, resume a normal diet, and take ibuprofen 3 times a day. He was further advised to rest, and report to the ED if persistent or worsening symptoms arose.
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The patient did not keep the Friday follow-up appointment. He died Saturday, two days after the ED visit, while playing basketball with his son. The autopsy report listed the cause of death as “a cardiac arrhythmia due to myocardial ischemia due to se­vere coronary atherosclerosis (heart attack).”

Allegations

Lawsuits were filed against both the EM physician and the family physician. The plaintiffs alleged that the EM physician was negligent for not immediately admitting the patient to the hospital. Allegations against the family physician involved the scheduling and management of the patient’s follow-up appointment.

Legal implications

In reviewing this case for the plaintiffs, an emergency medicine expert stated the patient should have been admitted for serial EKGs and cardiac enzymes to rule out acute coronary syndrome. A prompt stress test should also have been scheduled. The plaintiff’s emergency medicine expert indicated that had the patient been admitted, he would still be alive.
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To the defense experts who reviewed this case —  including two cardiologists and three emer­gency medicine physicians — the main weakness of the case was that the physician did not admit the patient or order repeat EKGs or cardiac enzyme tests.
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The EM physician stated that there were four pieces of information the patient did not share: history of playing tennis when the pain started; history of high cholesterol; history of having been seen at his employer’s health clinic that day; and history of a prior cardiac work up by a cardiologist. The physician stated had he known that the patient’s pain started when he was playing tennis, he would have admitted him as an urgent, but stable patient.
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For the focus of this article, discussion of what happened at the family physician’s practice is most relevant. Conflicting testimony was given by the family physician and the patient’s wife about the rescheduled appointment.
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The patient’s wife testified that when her husband called the family physician’s office on Friday to confirm the appointment, a staff member told him that the physician was booked all day and could not see him. The appointment was rescheduled for Monday.
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Upon reviewing the details of this case, a consultant reviewer felt the standard of care was not met because the patient’s follow-up appoint­ment was rescheduled by the physician’s office staff. The reviewer stated that if the patient had been seen as scheduled on Friday morning, treatment, referral, or advice could have been rendered that would have prevented his death.
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The family physician’s MA testified that when the patient called, he stated he was feeling better and did not want to come in that day. She told him that was fine and to come in on Monday, and in the meantime to follow the doctor’s instructions from the hospital. The MA did not check with the physician before telling the patient it was all right to come in on Monday.
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This conversation was documented in the medical record as “feels better and wants to wait until next week.” However, the MA admitted that she made this entry on Monday after the office had learned that the patient died. The entry was dated Friday.
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Patient accountability was an issue in this case. In his discharge instructions, the EM physician told the patient to “rest.” The patient’s wife acknowledged that the patient knew he should not play sports, but did not follow those instructions. The patient was playing basketball when he collapsed and died.

Disposition

This case was settled on behalf of both the EM physician and the family physician.

Risk management considerations

As discussed, establishing policies and procedures that outline appropriate staff communications with patients are recommended. Doing so may prevent staff from exceeding their authority and rendering advice or making decisions without the physician’s knowledge.
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Cancellation of and rescheduling appointments can be a challenging area to manage, but the addition of a few questions for staff to ask patients may be helpful. For example, asking if a patient has been recently discharged from a hospital visit might reveal information requiring a higher level of attention and escalation to a physician.
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In this case, due to the late documentation (after the patient’s death), it was unclear whether the patient was told the practice was too busy for him to be seen, or whether he initiated the rescheduling of his appointment.
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Protocols for documentation in the medical record apply to the entire health care team. Phone calls function as a key component of health care, and any communications regarding patient care should be documented in the record promptly. In this case, there were two instances of missing or late documentation: the conversation between the emergency and family physician and the phone call between the patient and MA that was not documented contemporaneously.

In addition, the late entry — after the patient’s death — by the MA was not identified as such and cast doubt upon the credibility of the entry. Any late entry to a medical record should be clearly identified and dated as such, with the signature of the staff member making the addendum. Any addendum should include the date and time of the actual encounter referenced, and the reason for the addendum.

Sources

1. Peikes DN, Reid RJ, Day TJ, et al. Staffing patterns of primary care practices in the comprehensive primary care initiative. Ann Fam Med. 2014;12(2):142-149. Available at https://pmc.ncbi.nlm.nih.gov/articles/PMC3948761/. Accessed July 22, 2025.
2. Occupational Outlook Handbook. Medical Assistants. U.S. Bureau of Labor Statistics. Available at https://www.bls.gov/ooh/healthcare/medical-assistants.htm. Accessed July 22, 2025.
3. Morris, G. 10 Reasons to Get Certified in Medical Assisting. Nurse Journal. Updated April 12, 2024. Available at https://nursejournal.org/articles/reasons-to-get-certified-in-medical-assisting/. Accessed July 22, 2025.
4. Taché S, Chapman S. What a medical assistant can do for your practice. Fam Pract Manag. 2005 Apr;12(4):51-4. PMID: 15889775. Available at https://www.aafp.org/pubs/fpm/issues/2005/0400/p51.html#fpm20050400p51-bt3. Accessed July 22, 2025.
5. Texas Administrative Code. Chapter 224 Delegation of Nursing Tasks By Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments. Available at https://texas-sos.appianportalsgov.com/rules-and-meetings?chapter=224&interface=VIEW_TAC&part=11&title=22. Accessed July 22, 2025.
6. Texas Occupations Code. Chapter 157 Authority of Physician to Delegate Certain Medical Acts. Available at https://statutes.capitol.texas.gov/docs/OC/htm/OC.157.htm. Accessed July 22, 2025.
7. Medical Board of California. Frequently Asked Questions. Available at https://www.mbc.ca.gov/FAQs/?cat=Licensees&topic=Medical%20Assistants. Accessed July 22, 2025.
8. Texas Health and Safety Code. Sec. 483.022. Practitioner’s Designated Agent; Practitioner’s Responsibilities. Available at https://statutes.capitol.texas.gov/Docs/HS/htm/HS.483.htm#:~:text=Sec.%20483.022.%20%20PRACTITIONER%27S%20DESIGNATED%20AGENT%3B%20%20PRACTITIONER%27S%20RESPONSIBILITIES. Accessed July 22, 2025.
9. Guttman OT, Lazzara EH, Keebler JR, Webster KLW, et. al. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety. J Patient Saf. 2021 Dec 1;17(8):e1465-e1471. Available at https://pubmed.ncbi.nlm.nih.gov/30418425/. Accessed July 22, 2025.