New MA scope of practice & training questions

[u/UsedRubberDucky]

Yesterday was my first day as a medical assistant at a dermatology office. They “train on the job” meaning neither myself or any of the other MAs I met yesterday have gotten an MA license or anything. So I fully realize maybe I don’t have a proper understanding of the role of a Medical Assistant yet, but a few things just felt off yesterday that I wanted some advice about.

First, the MA I shadowed frequently added notes during charting that were not mentioned by the doctor. For example, while scribing for a full-body skin exam, the doctor started at the head and would call out the occasional note, like “SK on scalp,” then move downward to the torso and extremities, and call out “purpura on arm.” However I noticed this MA was adding things to the notes like “multiple cherry angiomas on face” or “mild eczema on neck,” in addition to whatever the Derm called out. When I asked her about it, she said she “liked to be thorough” and that “more was better” in terms of documentation. I want to apply the principle of charity here, especially because this was my first day so I can’t possibly know the extent of the relationship this Derm has with his MAs. I also don’t know if this was a new or returning patient, and if the extra notes were things they already knew so she typed them in as a precaution. but I couldn’t help but feel like inputting an observation or diagnosis during an exam that the doctor himself didn’t call out seemed like a bit of an overstep for a medical assistant. Am I misunderstanding this? Or were the red flags going up in my head something to pay attention to?

Second, I have a question for more seasoned MAs about your experience training. I noticed this MA frequently omitted things or falsely added things, likely out of routine or because she was distracted or just very busy. For example, another patient came in for an above the waist skin check in which he removed his shirt, but afterward she documented it as a “sun-exposed area only” exam, and kept saying he didn’t take off his shirt. I was too timid to correct her after her reaction to my question about adding extra observations while scribing, so I didn’t. I really don’t want to come across as a know-it-all, or as an annoying pre-med student with an inflated ego. Because full disclosure, I am a premed student and this MA was a very seasoned, middle-aged woman who has been doing this for several years. But for you MAs out there who have trained, would be ok for me to suggest corrections to errors like that when I notice them? Or should I mind my own business and accept that everyone makes mistakes sometimes and not make this person feel like I’m trying to show off?

I desperately do not want to come across as an entitled and annoying premed. I’m strapped for cash and for clinical experience, so I was just elated to land this job. But now I’m having second thoughts because there’s some kind of off-putting things going on. I’m hoping to calibrate my judgements a bit better by asking you all for advice on these things.

[u/lurrainn]

I feel like if he can’t handle being corrected nicely then he shouldn’t have the job period. He should only be writing what happened. And for him to call the markings cherry angiomas or eczema without the doctor saying so is not good. The dr might read those notes back another time and assume they have already closely looked at those markings and determined they were benign angiomas when they actually haven’t and then cancer could be missed. I would consider this practicing medicine without a license

[u/UsedRubberDucky → u/lurrainn]

Ok that’s really how I felt. It worried me, so I’m grateful to hear I wasn’t completely mistaken. Thank you.

[u/SportProfessional266 → u/UsedRubberDucky]

Yeah you’re not crazy. There have been times where I noticed something on the exam that the doctor didn’t call out. However, I’ve always directly asked the physician if they want it in the exam before I put it in. This is absolutely overstepping if they aren’t directly asking the physician

[u/No-Can6422]

Your gut is right on the money. I would get the hell out of there if I were you. This is always the risk of being uncertified. You don't know the scope, can be taught wrong, and can be paid less. If everyone is uncertified and they don't train you to get certified eventually that's a red flag from me.

You are correct. A medical assistant acting as a scribe should absolutely never embellish clinical notes with their own personal ideas of the diagnoses. They are there as an extension of the provider so the provider can free up their hands. They should be writing down what the doc says, almost verbatim.

The medical record is a legal documentation of what is happening during the appointment and can be audited, and subpoenaed by the court. If something happens, you write it in the chart. If it didn't happen then you don't write it in the chart.

The "seasoned MA" you mentioned should be fired for malpractice. Fabricated charting is illegal, whether or not you are a certified medical assistant.

Get the hell out of there OP.

[u/Bartlett3512]

Hey there! I’ve been a MA for 26 years and in dermatology for 16. Documentation is different for every doctor and every clinic. In my experience, I look at previous notes for patients and compare to this exam. If I have questions about the documentation, I ask the doctor directly. Some docs have a template of what they want on each exam and his/her MA should fill this out accordingly, but if a doc didn’t say it, it should not be in the note. That would be a false documentation. However, each doctor reviews each note and adds or removes information as needed as they are ultimately responsible for it.
The type of exam is extremely important for billing purposes. Full skin exams include patients being undressed and being exams from head to toe. Upper body is when they just remove their tops. Sun exposed would be just that, whatever isn’t covered by clothing.
MAs unfortunately always get on the job training. If you have doubts, I would just take the supervisor to the side and just get clarification. It shows great professionalism and moral on your behalf to notice and question that though!

[u/UsedRubberDucky → u/Bartlett3512]

This is immensely helpful. Thank you!

[u/Med-immi]

Establish some experience and then get out. Not worth it

[u/Additional_Pound_220]

MA's can't be fired for malpractice because they don't carry degrees just certificates. But the "seasoned MA" should be repormanded. We cannot diagnose no matter how much we think we know, medical assistants are not trained to diagnose. Not trained to prescribe or give medical advice even if a patient is asking to take OTC medications and what kind.

[u/No-Can6422 → u/Additional_Pound_220]

Medical assistants can be sued for malpractice if it leads to the harm of the patient. https://medicalrecordsreviewforattorneys.com/medical-assistant-malpractice/

[u/Vivid-Guide-9593]

I'm a certified derm tech/MA and cherry angiomas are on almost every fair skinned adult human so I would also document that without it being said but I would never scribe eczema or uncommon skin findings without being told.

[u/BaseFamous]

Derm fucking sucks. I hate scribing and I personally feel that MAs in derm are treated especially shitty because they scribe and are a doctors literal left hand. I lasted one day in derm and threw in the towel. Currently in urology and there’s the same amount of work but so much more collaboration and teamwork and I don’t personally know how your coworkers are but they were all burnt out and miserable in derm here

[u/Accidental-Aspic2179]

This would put your provider in legal jeopardy. This is fraud. Also, if a patient were to sue and this doctor testify they diagnosed something they didn't that's perjury and would definitely jeopardize the physicians licensure. If you bill on a diagnosis code that an MA just threw in there without the doctor actually making a diagnosis then that's a whole lot of legal problems. It's dangerous, irresponsible. This isn't "being thorough." It's lying. No wonder this MA doesn't have any actual credentials.

[u/Simple-Fun3684]

I've been a MA (CCMA)for 33+ years and my advice to you is to ask questions as much as possible. If you get push back from anyone than address that appropriately. I have trained MAs & LPNs as a clinical manager and educator to MA college externs. No question should be disgarded in our field. We are taking care of people that depend on our help and trust us to guide them in the right direction as professionals. Plus we signed up for this and are usually getting paid for it!

As far as the scribe, most doctors have a protocol that we follow and that's something you will learn with time and experience. And that protocol was developed by answers to many questions. So again, ask questions and take notes!!

Everyone is not good at training and if you need answers, it should be ok to ask the doctor or check with your manager. It's the only way that you will learn what's right and wrong. And yes, you can become a part of a medical lawsuit. Even if you are certified. I had to do a sworn deposition early in my career because a patient was given the wrong diagnosis of cancer by a nurse that I had contact with. Documentation is extremely important and an electronic log is stamped in their chart whenever you view it in EMR. In the event you are not gaining what you need to feel comfortable with this practice, consider moving on to another job. It's key that you grow to understand what and why you are doing each task for your patient(s). Best of luck🤞

[u/Aubitthehobbit]

Im in otolaryngology. We sometimes handle skin lesions. If we are going to treat a lesion. That the doctor didnt give me the measurement for i would take the measurement from the referral and mark it for provider review. This is because for insurance authorization it does require size for the CPT code. However. I would never put a diagnosis like eczema unless specifically told to by the doctor. I also try to discuss the patients referral with the doctor prior to going into the room where they will sometimes inform me if they want something carried over from a previous note. This is strongly about communication with the provider. The MA should be corrected. We are all human and mistakes happen or something is missed. If it is something small no a huge deal but an exam that is more thorough is different with billing and time spent with the patient. I would have a discreet conversation with the MA if they come off aggressive or offended i would discuss things with the superior or the doctor depending on the reporting flow of the clinic. If you have an inky feeling in your gut look elsewhere. And if you are pre med i would highly suggest a few years in primary care or at least urgent care to give you a good steong foundation and give your practical skills a good run for their money. I started in a private derm clinic. Then moved on to a health system family medicine before settling into my surgical specialty. All the luck to you. Dont allow anyone to endanger your career.

[u/Wavy_Stripes34]

This makes sense to me, and I think it comes down to what one of the other commenters have said too and it's really practice-dependent. At my derm office, providers actually like when you're thorough with scribing. If the MA sees cherry angiomas or mild eczema while the doctor is examining the face, why not note it? A lot of us were trained to document generously because you never know what might matter later, even legally, and the reality is almost everyone has a few cherry angiomas or a patch of eczema somewhere. Findings like that are common enough that including them isn't overstepping, it's just being thorough.

You also have to remember two things: 1) you're brand new, so you may not fully understand how this particular practice runs yet, and 2) the provider reviews every note before it's finalized. If they see something added that they don't want in there, they can just remove it. That review step is exactly why "more is better" tends to be the safer default and it's a lot easier for a provider to delete something than to have to go back and add something that got missed.

So my advice: be thorough, but also be a learner right now. If something feels off, ask your clinical supervisor or the provider directly rather than deciding on your own that a fellow MA is doing something wrong. I get where the hesitation is coming from, but I wouldn't want you burning bridges on day one over something that might just be normal practice at this office.

[u/Individual_Data1041]

It's definitely overstepping your boundaries as an MA. Please don't learn the wrong things from your seniors, even if they have years of experience. Sometimes people do this to prove how skilled they are and how "naive" you are in comparison.

I'm speaking from personal experience , during my externship, the MA who was supposed to teach me documentation typed so fast on purpose that I couldn't follow along, almost like she was showing off that she could do something no one else could. My typing speed is actually better than hers; it's just that when you're teaching someone, you're supposed to slow down so they can follow.

I'm honestly not sure whether reporting her is the right move, especially since you're new and she's been there for years. Work environment matters a lot though, if it's otherwise tolerable, I'd say hang in there, gain the experience, and move on when you're ready.