Medical Assistant NotesTemplates & Documentation Guide
Complete guide to medical assistant documentation including intake notes, telephone triage, procedure assist notes, and scope of practice guidelines. With templates and real-world examples.
What Documentation Do Medical Assistants Complete?
Medical assistants (MAs) play a vital role in clinical documentation, serving as the bridge between patients and providers. Their documentation responsibilities include patient intake, vital signs, medical history updates, telephone triage, procedure assistance, and patient education - all of which contribute to continuity of care and accurate medical records.
Proper MA documentation is essential for patient safety, legal protection, billing accuracy, and quality care. Understanding what falls within your scope of practice and how to document effectively is critical for every medical assistant.
AI documentation tools like PatientNotes can help MAs capture patient information more efficiently during intake, freeing up time for direct patient care while ensuring complete, accurate documentation.
MA Documentation Scope of Practice
Understanding what you can and cannot document is essential for every medical assistant. Here's a clear breakdown of documentation scope.
MAs CAN Document
- ✓Vital signs and measurements
- ✓Chief complaint (patient's words)
- ✓Medical and surgical history updates
- ✓Current medications and compliance
- ✓Allergies with reaction types
- ✓Social history updates
- ✓Pre-visit screening results
- ✓Objective observations
- ✓Patient education provided
- ✓Procedure setup and assist activities
- ✓Specimen collection details
- ✓Immunization administration
- ✓Telephone messages and triage per protocol
- ✓Appointment scheduling notes
- ✓Refill requests (for provider review)
MAs CANNOT Document
- ✗Diagnoses or diagnostic impressions
- ✗Clinical assessments or interpretations
- ✗Treatment plans or medical decisions
- ✗Orders for tests, medications, or referrals
- ✗Prognosis or clinical predictions
- ✗Provider exam findings
- ✗Medical necessity statements
- ✗Counseling on diagnosis or treatment options
- ✗Independent clinical recommendations
- ✗Notes that imply independent medical judgment
Important Note
Scope of practice varies by state and employer. Always follow your facility's policies and your state's regulations. When in doubt, ask your supervising provider or practice manager.
Medical Assistant Note Templates
Use these templates as guides for common MA documentation tasks. Customize based on your facility's requirements and EHR system.
Patient Intake Notes
Documentation completed when rooming patients before provider sees them.
Key Elements:
Example:
INTAKE NOTE - 12/18/2024 10:32 AM MA: J. Smith, CMA Chief Complaint: "My blood pressure has been running high at home" Vital Signs: - BP: 152/94 (sitting, right arm, manual cuff) - HR: 78 regular - RR: 16 - Temp: 98.4°F oral - SpO2: 98% on RA - Weight: 185 lbs (gained 3 lbs since last visit) - Height: 5'10" - Pain: 0/10 Medications Verified: Patient confirms taking: - Lisinopril 20mg daily (taking as prescribed) - Metformin 1000mg BID (taking as prescribed) - Atorvastatin 40mg at bedtime (taking as prescribed) Allergies: NKDA - confirmed with patient History Update: Patient reports starting home BP monitoring 2 weeks ago. Readings ranging 145-160/88-96 per patient. Denies headaches, vision changes, or chest pain. Screenings: - PHQ-2: 0 (negative) - Fall risk: Low Patient ready for provider.
Telephone Triage Notes
Documentation of patient phone calls and triage decisions.
Key Elements:
Example:
TELEPHONE ENCOUNTER - 12/18/2024 2:15 PM MA: J. Smith, CMA Call Duration: 8 minutes Patient: Jane Doe, DOB 05/12/1975 Callback: (555) 123-4567 Reason for Call: Patient requesting advice for cough x 3 days Symptoms Reported: - Dry cough started Monday, now productive - Clear/white sputum - Mild sore throat - No fever (checked this AM: 98.2°F) - No shortness of breath - No chest pain Pertinent Negatives: Denies fever, chills, body aches, loss of taste/smell Triage Protocol: Respiratory Symptoms - Adult Disposition: Per protocol, symptoms consistent with viral URI. Advised: - Rest and fluids - OTC cough suppressant (Delsym or Robitussin) - Honey for sore throat - Call back if: fever >101°F, difficulty breathing, symptoms worsen or persist >7 days Follow-up: Schedule appointment if not improved in 5-7 days Provider Notification: Not required per protocol Patient verbalized understanding and agreed with plan.
Procedure Assist Notes
Documentation when assisting provider with procedures.
Key Elements:
Example:
PROCEDURE ASSIST NOTE - 12/18/2024 3:30 PM MA: J. Smith, CMA Procedure: Skin biopsy, left forearm Provider: Dr. Johnson Pre-Procedure: - Verified patient identity (name + DOB) - Confirmed consent form signed and witnessed - Reviewed allergies: NKDA, no latex allergy - Timeout completed per protocol Setup: - Sterile biopsy tray prepared - Lidocaine 1% with epi drawn up per provider - Sterile gloves available - Specimen container labeled prior to procedure During Procedure: - Maintained sterile field - Assisted with instrument passing - Applied pressure post-biopsy Specimen: - Specimen placed in formalin container - Label verified: Patient name, DOB, site (L forearm), date, provider - Pathology requisition completed Post-Procedure Care: - Pressure dressing applied - Written wound care instructions provided - Reviewed signs of infection to watch for - Follow-up in 7-10 days for suture removal and results - Patient verbalized understanding Patient tolerated procedure well. Left clinic in stable condition.
Medication Refill Notes
Documentation for medication refill requests.
Key Elements:
Example:
MEDICATION REFILL REQUEST - 12/18/2024 11:45 AM MA: J. Smith, CMA Patient: John Smith, DOB 03/22/1965 Medication Requested: Metformin 1000mg tablets, #60, 1 BID Pharmacy: CVS #4521, (555) 987-6543 Last Fill: 11/18/2024 (per pharmacy) Refills Remaining: 0 Compliance Check: - Patient taking as prescribed - No missed doses - Last A1c: 7.2% (10/15/2024) Side Effects: None reported Last Office Visit: 10/15/2024 (3 months ago) Next Scheduled: Due for follow-up Action: Per protocol, forwarded to provider for approval Note: Patient due for 3-month diabetes follow-up --- Provider Response: Approved. Schedule patient for follow-up within 2 weeks. Dr. Martinez, 12/18/2024 12:30 PM Refill sent to pharmacy: 12/18/2024 12:35 PM Follow-up scheduled: 12/30/2024 at 2:00 PM
Patient Education Notes
Documentation of teaching and instructions provided.
Key Elements:
Example:
PATIENT EDUCATION NOTE - 12/18/2024 4:00 PM MA: J. Smith, CMA Topic: New Diagnosis - Type 2 Diabetes Management Materials Provided: - "Understanding Diabetes" booklet - Blood glucose log sheets - Dietary guidelines handout - Glucometer quick reference card Teaching Completed: - What is Type 2 Diabetes (cause and effects) - Blood glucose monitoring demonstration * Return demonstration performed correctly - Target blood glucose ranges reviewed - Signs/symptoms of hypo/hyperglycemia - When to call the office - Importance of medication compliance - Basic dietary modifications Patient Understanding: - Assessed via teach-back method - Patient able to correctly state target BG range - Successfully demonstrated glucometer use - Verbalized understanding of diet basics - Identified hypo/hyperglycemia symptoms Barriers Identified: - Patient concerned about cost of supplies - Referred to social work for assistance programs Follow-up: - Diabetes educator appointment scheduled - Will reassess at next visit - Patient encouraged to bring glucose log Family member (spouse) present and included in education.
Immunization Notes
Documentation for vaccine administration.
Key Elements:
Example:
IMMUNIZATION ADMINISTRATION - 12/18/2024 9:15 AM MA: J. Smith, CMA Patient: Mary Johnson, DOB 08/15/1958 Vaccine Administered: Influenza (IIV4) - Fluzone Quadrivalent - Manufacturer: Sanofi Pasteur - Lot #: UJ123456 - Expiration: 06/30/2025 - Dose: 0.5 mL - Route: Intramuscular - Site: Left deltoid Pre-Administration: - Verified no contraindications (no egg allergy, not immunocompromised) - Screened for illness: No fever, feeling well - Previous flu vaccine reactions: None - VIS provided: Influenza 8/6/2024 version - Consent obtained and documented Administration: - Time: 9:15 AM - Administered by: J. Smith, CMA - Site prepped with alcohol swab - Needle: 25g x 1" - Aspiration: Not indicated per CDC guidelines Post-Administration: - Patient observed for 15 minutes - No immediate adverse reaction - Advised regarding common side effects: * Soreness at injection site * Low-grade fever possible * Fatigue, muscle aches Reported to: State Immunization Registry Registry submission confirmed Patient departed at 9:32 AM in stable condition.
Documentation Best Practices for MAs
Follow these guidelines to ensure your documentation is accurate, complete, and within your scope of practice.
Use Objective Language
Document what you directly observe or what the patient reports. Use "patient states" or "patient reports" rather than making clinical interpretations.
Be Specific and Accurate
Include specific measurements, times, and details. "BP 142/88 sitting, right arm" is better than "BP elevated."
Document in Real-Time
Document as you perform tasks whenever possible. This ensures accuracy and reduces the risk of forgetting details.
Know Your Scope
Only document within your scope of practice. When in doubt, clarify with your supervising provider or practice manager.
Use Approved Abbreviations
Only use abbreviations approved by your facility. Avoid dangerous abbreviations like "U" for units or "QD" for daily.
Maintain Patient Confidentiality
Follow HIPAA guidelines. Never leave patient information visible on screens and log out when stepping away.
Ensure Proper Signatures
Always include your credentials (CMA, RMA, CCMA) with your signature. Forward clinical notes for provider co-signature.
Complete Documentation
Incomplete documentation can lead to patient safety issues and billing problems. If interrupted, return to complete the note.
Approved Abbreviations for MA Documentation
Safe to Use
Do Not Use (ISMP List)
Frequently Asked Questions
What notes can medical assistants legally document?
Medical assistants can document patient vitals, chief complaints, medical history updates, allergies, medications, and objective observations. They cannot document diagnoses, treatment plans, or clinical assessments - those require provider signature.
Do medical assistant notes need to be co-signed?
Yes, clinical notes documented by medical assistants typically require provider review and co-signature. Administrative documentation like appointment scheduling and insurance verification usually do not require co-signature.
What is the difference between MA documentation and scribe documentation?
Medical assistants document their own clinical activities (rooming, vitals, patient intake) while scribes document the provider's clinical encounter in real-time. MAs can perform clinical tasks; scribes typically only document.
Can medical assistants use AI documentation tools?
Yes, AI tools like PatientNotes can help MAs document more efficiently by transcribing patient information and auto-populating forms. However, all clinical documentation still requires appropriate provider oversight.
What should be included in medical assistant intake notes?
MA intake notes should include: chief complaint (patient's words), vital signs with timestamps, current medications, allergies with reactions, relevant medical history updates, and any pre-visit screenings completed.
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