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Patient Care Report (PCR) Signatures Guide

PCR Signatures Guide

A Patient Care Report (PCR) holds significant legal importance for various reasons, particularly concerning reimbursement. Therefore, it must be true, accurate, and comprehensive

Certain indicators, such as PCR signatures and billed claims, carry legal significance and imply that the document is complete. Both signify that the PCR was reviewed and met the necessary criteria for reimbursement.

The reimbursement process with the Centers for Medicare and Medicaid Services (CMS) is meticulous. Several policies are in place to uphold compliance standards and preserve the integrity of the healthcare system. When submitting a claim to governmental payers, the billing entity attests that it complies with all applicable laws and prerequisites.

Who is required to sign?

Simply put, PCRs must contain signatures from the patient (or their authorized representative), a receiving facility representative, and the EMS personnel involved. 

The PCR should contain legible signatures of all individuals who performed interventions. These signatures validate the record, ensuring accurate documentation of interventions and verification by those directly responsible for the patient’s care. 

Recommendation to PCR Signatures

Patient – The PCR must contain the patient’s signature. If the patient is physically or mentally incapable of signing, an authorized representative may sign on the patient’s behalf at the time of service. The reason why the patient couldn’t sign must be specified in the PCR. The PCR should also inform the representative’s relationship to the patient in the signature section or narrative. 

Suppose no one else can sign for the patient. In that case, the medic at the scene and the Receiving Facility Representative may sign as a last alternative and provide a valid explanation. Read below for recommendations for PCR signatures for EMS Personnel and Facility Representatives.

EMS Personnel – The PCR must feature legible signatures and the current DSHS credentials of the EMS team responsible for the patient’s care. The PCR signatures must match the name on the EMS professional license. In cases of illegibility, the crew member should print their name and credentials alongside their signature. It is recommended that crew members sign PCRs using their full name, as indicated on their licenses, rather than using only initials or a first name.

Facility Representative – When transporting a patient, the EMS team should obtain a signature from a Receiving Facility Representative. The minimum requirement is the signatory’s full last name and first initial. If the signature is illegible, the representative must print their name under it. Including the signatory’s credentials and first name is preferred but not mandated. 

Review the § 424.36 of the Code of Federal Regulations for more information. 

If you have questions about PCR signatures, contact EMERGICON through our EMS & Client Hotline: 866-839-3671 | support@emergicon.com.

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