Documenting Staff Competency

Nurses, medical assistants, and other clinical staff must be properly trained and certified. However, this does not ensure that they are competent to perform clinical procedures. The Doctors Company recommends that physicians, or qualified supervisors, observe staff members as they conduct specific procedures and document their performance.

Examples of procedures that should be observed and documented are:

  • Taking patient histories.
  • Taking vital signs.
  • Giving injections.
  • Performing pulmonary function tests.
  • Performing EKGs.
  • Doing lab tests.
  • Running the autoclave.
  • Drawing blood.
  • Using the automatic external defibrillator.
  • Calling prescriptions in to the pharmacy.
  • Taking phone inquiries from patients regarding medical advice.

The procedures observed should be tied to the employee’s job description and yearly performance evaluation. Employee records should include documentation of training/education provided both inside and outside the office setting. Evaluating and documenting employee performance, training, and education helps to ensure the safety of your patients and the competence of your staff.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


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