How to Train Your MAs to do More Clinical Documentation

How to Train Your MAs to do More Clinical Documentation

How to Train Your MAs to do More Clinical Documentation

There are multiple reasons for physicians to train their medical assistants to do more clinical documentation. Not only does it save you time, it also helps them become more empowered in their own careers.

One of the problems physicians sometime experience in EMR adoption stems from their erroneous belief that they have to do everything themselves, and that’s simply not true. Today we have four tips to help you train your medical assistants to do more clinical documentation.

Let Go of The Process

Many physicians are inherently distrustful of anyone else doing their documentation -- and that’s understandable. When nurses or MAs do it, the doctor may feel uncomfortable having records under their own name being recorded by someone else. But, by giving up a little bit of ownership, you can take advantage of your staff’s talents and save yourself time and effort.

Remember that the happiness you feel with your EMR is inversely related to the time you spend dealing with it. It’s helpful as long as everyone uses it to work toward the same goal and is empowered to the full extent of their training to do the clinical documentation that’s required.

Make a Plan

Ensuring success with having your MAs do more documentation starts with hiring the right type of MAs to work in your practice. By hiring people who are self-starters and eager to learn as much as possible, you’ll lay the foundation for success.

Set high expectations for the work you want them to do, and train them to meet those expectations. Finally, ongoing training can help ensure that everyone is getting the most out of the system.

Get Your EMR Set Up Properly

For example, it’s important to have past medical history items easily referenced in the EMR system. If someone comes in with a past medical history of a atrial fibrillation, there are many ways to describe it -- such as AF, a-fib, PAF, atrial fib and so on. By standardizing these names in the past medical history section of the EMR everyone works with the same terminology.

Encourage MAs to Work to the Top of Their Training

The employees at your clinic are prepared to work at a variety of levels. By maximizing their contributions at the top of their training, you’ll get the most out of them and they’ll get more satisfaction out of their jobs. 


There has been some confusion regarding the role of physicians and medical assistants when it comes to documenting past medical and surgical history, family history, social history and review of systems. But, it is well established that ancillary staff are permitted to document these items, as long as the provider verifies the accuracy of the data in the record. 

Training your MAs to take on more medical documentation is a key part of running an efficient practice. Take advantage of the EMR’s features to make it easier for your MAs to help with medical documentation.

Logan Solutions uses a combination of clinical practice expertise and technological skill to help physician practices throughout the U.S. implement, customize and improve their ERM and Dragon Medical software systems. Contact us to find out how our clinical-practice expertise can help your practice with its clinical documentation software needs.