Is order entry a physician-only EHR task?

This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.

Members of the care team assisting with documentation, including nurses, credentialed medical assistants, or non-credentialed staff members may enter orders in the electronic health record (EHR) under physician direction in a manner consistent with state and institutional policies. Additionally, there is no current Medicare EHR incentive program that requires computerized provider order entry (CPOE).¹ 

CPOE is the process of electronic entry of physician and advanced practice provider (APP) orders for diagnosis and treatment of patients (e.g., prescription medications, lab and imaging tests, referrals, etc.). 

The Centers for Medicare & Medicaid Services eliminated the previously required CPOE and clinical decision support objectives and associated measures.¹ Similarly, The Joint Commission has eliminated previous prohibitions on documentation assistants entering orders on behalf of physicians.²

Medical decision making and ensuring quality and safety by overseeing processes for selecting the proper order and associated diagnosis remain the responsibility of the physician or APP.

Delegating order entry to care team members can increase practice efficiency, improve care gap closure, reduce physicians’ administrative burden, and encourage non-physician health care professionals to take on new tasks and operate at the top of their license.

• STEPS Forward® Toolkit: Team Documentation
• STEPS Forward Playbook: Taming the EHR
• Download this myth: Is order entry a physician-only EHR task? (PDF)

1. Centers for Medicare & Medicaid Services (CMS). CMS Finalizes Hospital Outpatient Prospective Payment Changes for 2017. CMS. November 1, 2016. Accessed December 6, 2024. https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-hospital-outpatient-prospective-payment-changes-2017
2. The Joint Commission. Documentation Assistance Provided By Scribes: What Guidelines Should be Followed When Physicians or Other Licensed Practitioners (LP) Use Scribes to Assist with Documentation? The Joint Commission. July 26, 2018. Accessed December 6, 2024. https://www.jointcommission.org/standards/standard-faqs/ambulatory/record-of-care-treatment-and-services-rc/000002210/

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Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.