Administration and Leadership, Documentation & Patient Care Reporting, Expert Advice

How to Write Good Patient Care Reports, Part 5 (of 5): Improving Legibility

Last month, we shared the fourth part of a five-part series on writing good patient care reports (PCRs), which focused on providing a detailed narrative (See full article: How to Write Good Patient Care Reports Part 4: Providing a Detailed Narrative). In the last part of this series we focus on improving legibility in your PCRs and all attached forms. Encourage your staff or colleagues to use these criteria as guidelines to writing complete and accurate PCRs that reduce the chance of insurance denials. 

Criterion 5: Are the signatures and handwritten sections in your PCRs legible? 

While writing your narrative for each PCR, check all the following information:

All signatures must be present and legible: Your patient care report must be legible. This includes all signatures. If the patient’s or provider’s signature is not legible, you can print their names and credentials below the signature line.

  • The patient or a family member must sign the patient care report. Print or type the person’s name that is signing the report below or next to the person’s signature, and include their relationship to the patient.
  • Crew members’ physical and/or electronic signatures must be included on the report. Signatures must be legible or the crew member’s name must be printed or typed on the report along with their credentials as a certified technician.
  • Healthcare providers at the receiving facility should sign the patient care report. This should be the person that has received the patient and your report on your assessments and treatments. Print or type the name of the person signing the report along with their credentials.

Make sure your handwriting is readable: Some people have poor handwriting. If you are one of these people, take a little extra time if you are producing a handwritten report to make sure others can read the information you provide.

All information on any attached forms to the patient care reports must be legible: The information on other forms such as the Physician Certification Statement (PCS) or Advanced Beneficiary Notice (ABN) must be legible as well. For example: Are the detailed medical reasons on the PCS form that made the transport by ambulance medically necessary readable? The name and signature of the person signing the PCS form must be legible, with their name printed or typed next to their signature along with their credentials.

This concludes our 5-part series on how to write good patient care reports. We hope you have found this series helpful in developing accurate and detailed PCRs that will surely result in better care for your patients and improved reimbursement from insurance companies.

Grant Helferich is the EMS advisor/client trainer with Omni EMS Billing in Wichita, Kan. He has worked EMS for over 35 years.