Thanks to the outstanding work of the North Dakota Society of Medical Assistants, and the cooperation of the North Dakota Board of Nursing, on August 1, 2005 Certified Medical Assistants regained the right to be delegated the administration of medication by intramuscular, subcutaneous, and intradermal injections.

The following is a chronology of events that led to this landmark victory.

For many years North Dakota physicians had been permitted to delegate the administration of medication by injections to medical assistants working under their direct supervision. On March 8, 2004, North Dakota Attorney General Wayne Stenehjem issued Letter Opinion 2004-L-20 to Richard Riha, Burleigh County State’s Attorney. The following are pertinent excerpts from this letter opinion:

“This office has consistently found that the prescription and administration of medication is so inimically [sic] connected to the health of the public that it is for the Legislature to determine which persons are authorized to prescribe or administer medication.” North Dakota Attorney General (NDAG), 99-F-09. Medication administration is included within the definition of nursing. North Dakota Century Code (NDCC), 43-12.1-02(5)(c).

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Section 54-07-05-02(2), [NDAC], defines a “medication assistant” to mean “an individual who has a current registration as a nurse assistant, has successfully completed an approved medication assistant program, has demonstrated competency in the administration of routine, regularly scheduled medications, and possesses a current registration from the board as a medication assistant.” Chapter 54-07-05, NDAC, includes the requirements for registration as a medication assistant and allowable types of medication administration by a medication assistant. Ch. 54-07-06.1, NDAC, and 54-07-07 include the requirements for board-approved medication assistant programs.

In the wake of this letter opinion of the attorney general, the North Dakota Board of Nursing (Board) was faced with a number of questions about the legality of medical assistants being delegated medication administration. The Board consulted legal counsel, and received the following letter of March 16, 2004:

Dear Board Members:

You have requested a legal opinion regarding the role of a medical assistant in the administration of medication. More specifically, you have inquired whether a medical assistant must hold a current license or registration issued by the Board before he or she can administer medication. For the reasons set forth below, I believe that a medical assistant generally must hold a current license or registration in order to participate in medication administration.

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The Legislature has specifically included “medication administration” within its definition of nursing. NDCC 43-12.1-02(5)(c). As a result, the administration of medication is a nursing intervention that falls within the scope and regulation of the Nurse Practices Act. NDAC 54-07-05-01. Although some persons are exempt from the provisions of the Nurse Practices Act, there is no exemption for medical assistants. NDCC 43-12.1-04.

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Section 54-07-05-02(2) of the North Dakota Administrative Code defines a “medication assistant” to mean an “individual who has a current registration as a nurse assistant, has successfully completed an approved medication assistant program, has demonstrated competency in the administration of routine, regularly scheduled medications, and possesses a current registration from the board as a medication assistant.” The requirements for the board-approved medication assistant programs are set forth in Chapters 54-07-06.1 and 54-07-04 of the North Dakota Administrative Code.

Based upon the foregoing legal authority, it is my opinion that medication administration must be performed by a nurse licensed under Chapter 43-12.1; by some other person licensed or registered under Title 43 of the North Dakota Century Code who is acting within the scope of his or her license or registration; by an unlicensed assistive person who has been properly delegated the delivery of a specific medication for a specific client; or by a medication assistant acting pursuant to appropriate delegation from a licensed nurse. The medication assistant must have completed a Board-approved program of medication administration and possess a current registration from the Board as a medication assistant.

Medical assistants are currently not licensed or registered under Title 43 and therefore are not independently authorized by the Legislature to administer medication. Accordingly, in order to participate in the administration of medication, medical assistants must obtain registration from the Board as a medication assistant…

It is my understanding that the course work for a medical assistant may exceed the requirements for the medication administration programs currently approved by the Board. For that reason, you may want to encourage the program providers to obtain Board approval of their programs so that their medical assistant students can become medication assistants. It is my further understanding, however, that the medical assistant may be educated to administer routes or types of medications beyond what is currently allowed for medication assistants in Section 54-07-05-09 of the North Dakota Administrative Code. Nevertheless, under the current structure of the Nurse Practices Act and the rules promulgated thereunder, no unlicensed assistive person, whether educated as a medical assistant or not, may administer medications beyond the scope allowed for medication assistants registered by the Board. In order to create an expanded scope of practice for medical assistants, I think the Board would need to first obtain direction or authorization from the Legislature or perhaps promulgate additional rules.

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Brian L. Bergeson, Attorney at Law

SCHULZ LERVICK GEIERMAN & BERGESON LAW OFFICES, P.C.

II. 

In light of these legal opinions, on May 18, 2004, the North Dakota Board of Nursing convened a task force to study the issue of medical assistant practice. The goal of the Medical Assistant Task Force was “to provide guidance and make recommendations to the Board in the area of medical assistant practice.” The Task Force was composed of “representatives from the Board of Nursing, RNs, LPNs, medical assistants, and representatives from the North Dakota State Board of Medical Examiners or the North Dakota Medical Association.” The Task Force met June 16 and July 12, 2004.

The Task Force recommended that the Board of Nursing not attempt to include in its regulations the delegation of injections to medical assistants. The consensus was that medical assisting practice should be primarily under the jurisdiction of the North Dakota State Board of Medical Examiners, and that legislation giving this board rule-making authority would have to be introduced in the North Dakota legislature. This recommendation was forwarded to the Board of Nursing.

The North Dakota Society of Medical Assistants, with the knowledge and approval of the Task Force, then formed a coalition to draft a suitable piece of legislation, garner support for it, and determine the best strategies for its enactment. Representatives of the North Dakota State Board of Medical Examiners, Medical Association, Board of Nursing, Nursing Association, physicians, nurse practitioners, Registered Nurses, Licensed Practical Nurses, Certified Medical Assistants, and Registered Medical Assistants (American Medical Technologists) were included in the coalition. The coalition met August 14, 2004.

The coalition members agreed that a bill should be drafted that would add to the list of exemptions from the licensing requirements of the Medical Practice Act. The following language was approved:

Any person rendering services as a medical assistant if such service is rendered under the supervision, control, and responsibility of a licensed physician. The State Board of Medical Examiners shall prescribe rules governing the qualifications and supervision of medical assistants…

The draft language was to be shared with all the pertinent communities of interest. However, when Shawn Boger, CMA, leader of the coalition and then President Elect of the North Dakota Society of Medical Assistants, returned home from the meeting, she discovered that she had just received the following letter from Rolf P. Sletten, Executive Secretary and Treasurer of the North Dakota State Board of Medical Examiners:

Dear Ms. Boger:

I have shared the materials you forwarded to us with all of the members of the Board of Medical Examiners. Over the past several years we have been approached by a number of groups who have asked us to expand the role of the Board to include regulation of various groups of people who provide services in the medical field. We have always resisted those overtures. It is our feeling that the Board of Medical Examiners can best serve the public if we continue to keep a rather narrow focus on our original mission. In other words, we feel very strongly that the Board’s role should not be expanded beyond the regulation of physicians and physician assistants.

Please understand that we recognize the importance of the role played by Medical Assistants in the healthcare delivery system. The work done by Medical Assistants is important to patients and to physicians alike. Our point here is simply that some other regulatory scheme should be devised. You are not the first group to approach us with this sort of request. Our response is always the same.

We hope you will find a solution to the issues you are facing but that solution is not to be found in an amendment to the Medical Practice Act.

Clearly, with such an unequivocal rejection of this legislative strategy by the Board of Medical Examiners, another approach was needed to restore the right to be delegated injections.

III. 

The North Dakota Society of Medical Assistants informed the Board of Nursing of the posture of the Board of Medical Examiners. After extensive discussions between the Society and the Board of Nursing, the Board agreed to propose amendments to its regulations that would permit certain medical assistants to be delegated the administration of medication by intramuscular, subcutaneous, and intradermal injections. The amendments would create a medication assistant III category, and would permit certain formally educated and credentialed medical assistants to be registered under this category.

The following are key excerpts from the proposed amendments to the North Dakota Administrative Code with added language underlined:

Chapter 54-01-03, Definitions, 32. “Medication assistant” means an individual who has a current registration as an unlicensed assistive person, has had additional training in administration of medications, and possesses a current registration from the board [of nursing] as a medication assistant.

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c. Medication assistant III is a person who has completed two semesters of nursing school, each of which must have included a clinical nursing component, or a graduate of a board recognized medical assistant program.

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54-07-05-05…

4. Unlicensed assistive persons may obtain initial medication assistant III registration by:

a. Showing satisfactory evidence of successful completion of two semesters of nursing school, each of which must have included a clinical nursing component. The two semesters combined must have included basic clinical skills, basic pharmacology, principles of medication administration, and math competency; or

b. Showing completion of a board recognized medical assistant program.

1) The applicants have successfully passed the certifying examination from the American Association of Medical Assistants (AAMA) or its successor organization awarding the CMA credential or registration from the American Medical Technologists (AMT) or its successor organization awarding the RMA credential.

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54-07-05-06. Medication assistant registration renewal…Medication assistant registry listing renewal requires verification of continued competency or evidence of certification or registration.

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54-07-05-08. Medication assistant registration disciplinary action. The registration issued to an unlicensed assistive person, including the medication assistant registration, may be revoked, suspended, encumbered, or denied based upon the provisions of chapter 54-02-07.

54-07-05-09. Routes or types of medication administration.

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3. Medication assistant III students and medication assistants III may administer medications by the following routes to individuals or groups of individuals with stable, predictable conditions according to organization policy:

a. Intramuscular injections;

b. Subcutaneous injections;

c. Intradermal injections.

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5. Medication assistant students and medication assistants III may not administer medications by the following routes:

a. Central lines;

b. Colostomy;

c. Intravenous medications;

d. Heparin lock;

e. Nasogastric tube;

f. Nonmetered inhaler;

g. Non unit dose aerosol/nebulizer; or

h. Urethral catheter

A public hearing on the proposed amendments was held April 4, 2005. All communities of interest were overwhelmingly supportive. The amendments were approved by the attorney general and the Administrative Rules Committee of the legislature, and went into effect August 1, 2005.

 IV.

This author highly commends the North Dakota Society of Medical Assistants—especially Karen Emineth, CMA, Shawn Boger, CMA, Beth McMahon, RN, MSEd, and Kim Scheidecker, CMA—for regaining the right to be delegated the administration of medication by injections. This monumental accomplishment could signal a new strategy for protecting the right to practice and securing legal recognition and differentiation of the Certified Medical Assistant® (CMA) credential.

Questions? Contact Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org or 800/228-2262.