Administration and Leadership, Columns, Commentary

Pro Bono: Signing the Patient Care Report

Issue 6 and Volume 43.

PCR signatures are an essential part of patient care, accountability & compliance

The patient care report (PCR) is the official medical and legal record of your contact with the patient. One of the most important elements of a complete PCR is the provider’s signature. Why? You’re providing professional medical care to the patient!

An accurate and complete PCR signed by the caregiver completing the report is an essential part of that patient care.

Signing off on the PCR is also necessary to have a complete medical and legal record of the patient encounter, and the PCR becomes part of the patient’s records in the hospital.

Your signature can be handwritten as part of a paper report, or the report can be signed electronically. Most electronic PCR solutions have effective ways of capturing your actual digital signature with a stylus, or your typed name as an electronic signature.

Electronic signatures will suffice as long as there are proper login and access controls so that it can be verified that your digital name in the signature block of the report means you personally signed the PCR.

Your signature must also include your printed name and your credentials or certification level. That should appear immediately under the signature line.

This is especially important when the signature of the person completing the report is illegible. It also helps to ensure continuity of care, and that the assessment and treatment was provided by properly certified EMS practitioners in accordance with your state’s EMS laws.

Documentation of credentials identifies the level of certification of the provider and helps verify the that the crew and vehicle requirements are met for the respective level of service provided (i.e., ALS vs. BLS).

In a nutshell, signing the PCR and documenting your credentials helps ensure compliance with legal and ethical requirements.

One of the most common questions we get when teaching EMS documentation is, “If I’m the primary caregiver completing the PCR, do the other crew members need to sign it?” Or, “Does the EMS law in our state require that all crew members sign the PCR?”

In most states, the EMS laws don’t expressly state that all crew members must sign the PCR.

Usually, laws require the primary caregiver to complete the PCR. However, having all crew members sign the PCR is a standard for EMS documentation that should be followed for three primary reasons.

Responsibility

First, Medicare and other payers require that those who provide services to the patient must sign for those services.

Specifically, the Medicare Program Integrity Manual, chapter 3, section 3.3.2.4 states, “Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary.”

Even if you’re the designated “driver” on the call and weren’t the primary caregiver, you were still involved in the assessment and, to some extent, are responsible for the care of the patient.

You’re responsible for the care you provided to the patient—even if you simply obtained vital signs or helped lift and move the patient.

This requirement also makes good sense. Since we’re providing medical care, everyone involved with the patient must be accountable for the care we’re providing—lives are at stake!

Transparency

Second, it’s simply good medical care for all crew members to sign the PCR. Healthcare is all about accountability and transparency. Even if you’re not the primary care provider, you participated in the patient encounter. When providing medical care, everyone involved with the patient must be accountable for the care they provide, and all crew members should sign the PCR if you want to call it a complete medical record.

Fresh Eyes

Third, it’s a good “check and balance” for all crew members to sign. When you sign the PCR, you’re obligated to review it. Having more than one set of eyes on the report helps tremendously in reducing errors and omissions in documentation.

For example, on a busy shift, a crew member who wasn’t the primary caregiver may pick up on an omission in documentation when reviewing it (e.g., the failure to document that oxygen was administered).

Quality assurance starts with providers checking each other’s work, including the PCR documentation. The earlier those errors are picked up, the better—and the more promptly reimbursement can be sought for your services.

Requiring that all crew members review and sign the PCR is a best practice for ensuring that you have a complete and accurate medical and legal record of the patient encounter.

The bottom line is that legibly signing your patient care reports, including your printed name and credentials, is a fundamental standard of care for PCR completion and an essential part of being a healthcare professional.