Which component of a patient's medical record is a medical assistant NOT permitted to sign or initial?

• A. Allergies
• B. Medications
• C. Diagnosis
• D. Immunizations

Answer: (C)

Scope of practice and who can sign entries in a patient record. Diagnoses are medical judgments made by licensed clinicians based on evaluation and test results. Signing or initialing a diagnosis would imply endorsement of a clinical conclusion, which is outside a medical assistant’s scope of practice. Medical assistants can document factual information such as patient-reported allergies, current medications, and immunization records under supervision. These are data points within the chart, not professional diagnoses, so they can be recorded or initialed by the MA while the clinician retains responsibility for the diagnostic decision.