EMS Patient Care Report Documentation Best Practices

EMS Patient Care Report Documentation Best Practices

According to the Centers for Medicare and Medicaid Services (CMS), there are some criteria that an EMS Patient Care Report (PCR) must observe to be compliant for EMS claim reimbursement. Although there are multiple reasons to be thorough while completing a PCR, the primary motivation is to provide an accurate, truthful, and complete record of the patient’s condition and treatment provided on the EMS call.  

What is an EMS Patient Care Report?

An EMS patient care report (PCR) is a written or electronic document that emergency medical personnel create when they respond to a medical emergency or transport a patient to a medical facility.

Medicare sets the standards for the insurance and billing industry. Therefore, meeting the Medicare guidelines is the first step to a quick and successful reimbursement. The level of service provided (BLS, ALS, ALS2, or SCT and emergent vs. non-emergent) determines the reimbursement rate. It’s crucial to have detailed documentation for processing a claim for the correct level of service.

EMERGICON’s teams are experts in processing claims compliantly and efficiently. Here are some documentation best practices for preparing an EMS Patient Care Report. 

Detailed narrative

The Chart Documentation must support the medical necessity for ambulance transport. The Patient Care Report must “paint a colorful picture” of the patient’s condition, medical interventions, medications administered, and services provided. The narrative should contain, at minimum, a reference to the patient assessment, the clinical evaluation, and any response to treatment provided while in route.

It’s also essential to include the following in the narrative:

  • The nature or type of dispatch. 
  • How the patient was found when arriving at the scene.
  • How the patient was moved to the ambulance.
  • Dosages of any medication administered.
  • Supplies used during the call. 
  • Description of any safety issues.
  • When monitoring an existing IV, describe if it is locked or flowing. 
  • When trauma is the cause of suspected injuries, describe the traumatic event.
  • Observations at the scene (if other EMS responders and/or law enforcement are present).

Transport information

Every Patient Care Report must provide: 1 – date of transport, 2 – pick-up address, 3 – drop off address, 4 – facility name, 5 – facility address, 6 – fractional mileage, and 7 – EMS agency name. 

Medicare requires that every claim discloses fractional mileage. Track the mileage from the time of dispatch to upon arrival and report the nearest tenth of a mile. The rule is valid for all claims up to 100 loaded miles. After mile 100, round up to the nearest whole mile. 

Patient information

In addition to the patient’s condition described in the narrative, the Patient Care Report should also provide the patient’s name, address, date of birth, and resident status.

Legible signatures

Patient Signatures – To process a claim, the Patient Care Reports must contain the patient’s signature. If the patient cannot sign, an authorized representative may sign on the patient’s behalf at the time of service. That representative’s relationship to the patient should be identified and documented in the signatures section or referenced in the narrative. 

In case no one else can sign for the patient, the EMT or Paramedic at the scene and the Receiving Facility Representative may sign as a last alternative and provide a valid explanation.  

Facility Signatures – A signature should be obtained from the Receiving Facility Representative when transporting a patient. This signature confirms that the facility has received a report and is taking responsibility for the patient’s care. 

The minimum requirement for the Receiving Facility Representative Signature on the PCR is a full last name and a first initial. If the signature is illegible, the representative must print their name under the signature. Including the signatory’s credentials and first name is preferred but not mandated. 

Medic Signatures and Credentials – A Patient Care Report must contain signatures and up-to-date DSHS credentials of the EMS crew that responded to the call. These signatures must be legible and match the name on the EMS personnel license. If illegible, the crew members should print their name and credentials with their signature. 

An important recommendation is that the crew members sign the PCRs using their full name, as it appears on their licenses, instead of using only initials or a first name.

If you have any questions, contact EMERGICON’s teams through our EMS & Client Hotline: 866-839-3671 |

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