Effective: 05-12-23
Supersedes: 08-04-21
Purpose: The Patient Care Report (PCR) is the fundamental tool for documenting the care and services we provide to our patients. The PCR is an important medical record that must document available information regarding the incident, patient assessment, and care provided to the patient in a clear, concise, and complete manner.
The PCR also forms the basis for determining the amount and responsible party for reimbursement. Therefore, the PCR must accurately describe the response, assessment and treatment provided to each patient so that billing personnel may accurately determine the level of service that is to be billed along with an accurate summation of those services provided.
Policy: Unless cancelled prior to arrival on scene, responding ambulance crews are required to complete a Patient Care Report (PCR) for each response. The PCR should include all applicable information about that particular EMS response. Each patient care report shall be accurate, prepared contemporaneously with or as soon as practicable after, the EMS call that it documents, and shall, at a minimum, include all required patient care and billing data elements.
Patient Assessment and Treatment Information
The PCR should document the history of the patient’s present illness or injury and the present condition of the patient. Include all associated symptoms that the patient is experiencing and other pertinent medical information that is obtained during the patient assessment. Pertinent negatives should be documented on all assessment questions asked. The completed PCR should include a description of all procedures, interventions, or medications provided as well as the time they were performed, by whom, and any resulting changes in the patient’s status.
All baseline printouts from equipment used in the care of the patient, and those parts of printouts that correspond to clinical interventions or clinically relevant changes in the patient's condition, shall be available as part of the patient care report. Any additional supporting documentation, such as patient “face sheet”, medical necessity form, section 12, etc. should have the run number and date documented.
ALS Assessment / Refer to BLS
Advanced Life Support (ALS) personnel who have established direct patient contact must complete an appropriate assessment in accordance with the standards of their certification and training. If ALS personnel determine that an ALS intervention is not needed or anticipated and the patient’s needs are within the BLS scope of care, the patient may be referred to BLS for transport to an appropriate health care facility. Paramedics must document their assessment and clear the incident with “Treated, Transferred Care to Other EMS Unit” disposition. EMS agencies are entitled to submit for reimbursement of an ALS assessment, so it is important that it be properly documented for medical, legal, and financial purposes.
Patient Refusal
A patient refusal shall be thoroughly documented whenever a competent patient refuses to be treated and transported to the hospital. The patient, parent, or legal guardian should sign the designated refusal section of the PCR. In cases where a computer is not available, the patient refusal may be documented on a paper Patient Refusal form.
Financial Responsibility and Assignment of Benefits
Patient Signature: Whenever the patient is capable of signing the assignment of benefits form, the ambulance crew must, at the time of service, get the patient (if over 18) to sign. If the patient is a minor, the patient’s parent or legal guardian should sign on behalf of the patient. The patient should not be asked to sign if they are physically or mentally incapable of signing. Examples of this include an unconscious patient, a patient who is mentally incapacitated, a patient under the influence of drugs or alcohol, a patient who is restrained and unable to sign, a patient in great pain, or a critically ill or injured patient.
Authorized Signature: If the patient is physically or mentally incapable of signing at the time of service, the ambulance crew must properly document the patient’s incapacity. When the patient is incapable of signing, the crew should then attempt to get a signature of an authorized representative. Medicare regulations permit only the following Authorized signers to sign on the patient’s behalf:
· The patient’s legal guardian;
· A relative or other person who receives social security or other governmental benefits on behalf of the patient;
· A relative or other person who arranges treatment or handles the patient’s affairs; or
· A representative of an agency or institution (such as a nursing home or skilled nursing facility) that furnishes other care, service, or assistance to the patient.
Receiving Facility Signature
A representative of the receiving facility must sign a statement on the Patient Care Report confirming receipt of the patient at the time of transport. The representative may be a clerk or other administrative personnel, a nurse, a doctor, etc. Signing does not obligate any responsibility for payment either personally or to the hospital, but is merely a confirmation of transport.. If there is no one available to sign the statement, obtain a copy of the admission form or face sheet that shows the date and time of transport.
Non-Emergency Transports and “MedNec”
The Physician Certification Statement (PCS) / Medical Necessity Form (MedNec) are required on all non-emergency transports, and should be completed and signed by the appropriate individual at the time of service. The only exception would be patients pre-authorized to receive repetitive, scheduled non-emergent transport for the purposes of dialysis, cancer treatment, or other ongoing treatment. All other non-emergency transfers should have an electronic PCS obtained on the laptop at the time of transport.
Patient signatures and Medical Necessity Forms are the responsibility of the transporting crew. The Medical Necessity form must be signed by a Physician, Physician Assistant, Nurse Midwife, Dentist, Nurse Practitioner, Managed-Care representative, or someone designated by the Physician (typically an RN or LPN). When the form is filled out by a Physician Designee, the ordering Physician’s name (first and last name) must be added in the field under “RN Supervising Physician”.
Submission of the Patient Care Report
After the Patient Care Report is documented, click “Complete PCR” to ensure all mandatory fields are populated. If all required fields are populated, the author will be prompted to complete (or lock) the PCR by inputting their password. Once complete, the PCR can then be submitted by selecting the “Save to Server” button. The completed PCR will be uploaded to the Company server, and a copy of the PCR will be automatically faxed to the receiving hospital.
Handwritten / Paper Documentation
In the event a handheld device is not available, all required information shall be documented on a standard paper PCR and (if applicable) Patient Refusal form. A copy of the paper PCR report must be left at the receiving facility. Any paper generated 51-A reports, patient refusals, PCRs, or other patient care related documentation should be sealed in an envelope and left at the base for collection.
Amendment of Patient Care Reports
PCRs create a legal record of an ambulance call. It is the responsibility of all personnel to ensure that their PCRs accurately reflect patient information, care given and the medical condition of the patient. To that end, Supervisory personnel or management of Brewster Ambulance Service may request that staff members modify, amend or fully complete PCRs for a given call when PCR reviews suggest that the information documented may be incorrect or incomplete. Information for each patient call must be complete, accurate, honest and wholly based on the patient's condition. It is legally permissible for staff members to amend PCRs for reasons of completeness, correction, and clarity, and in compliance with the procedures outlined below. Brewster Ambulance Service does not endorse nor will it tolerate any staff member who embellishes or falsifies medical necessity, mileage, services rendered, supplies used or any other information for the purpose of obtaining or enhancing reimbursement.
Proper reasons for modifying a patient care report may include correcting erroneous information, such as the patient's name, address, insurance numbers, incident number, or patient care-related information. Medical information on PCRs should only be modified by the original author. When an amendment of medical information is required, arrangements may be made for the original author to come to the Administrative Headquarters where the ePCR will be “reopened” by a system administrator, and any necessary modifications or additions may be made. Any modification will automatically be time stamped by the computer system to clearly show the amendment and when the changes were made. Other personnel (billing, QA, etc.) may amend patient demographic information (name, address, insurance numbers, mileage, etc.), correct spelling errors and make other changes not related to patient care documentation. In all cases, any change to a previously submitted PCR (either electronic or hand written) shall include the name of the person making the change, as well and the date and time the change was made.
Mileage Reporting
The transporting vehicle operator should note the mileage utilizing the trip odometer when initiating transport, and again when the transport is complete and report the difference rounded up to the nearest tenth of a mile to the person completing the PCR for all transports.
Abbreviations / Standard Terminology
To help reduce medical errors related to incorrect use of terminology, only standardized, commonly accepted abbreviations should be used. One of the major causes of medication errors is the use of potentially dangerous abbreviations and dose expressions. Examples of especially problematic abbreviations include the use of trailing zeros (e.g., 2.0 vs. 2) or use of a leading decimal point without a leading zero (e.g. .2 instead of 0.2). The decimal point is sometimes not seen when dosages are handwritten using trailing zeros or no leading zeros. While the initiative was intended for in-hospital use, the same safety concepts are applicable to the prehospital setting as well because patient medication information and field treatment notes are often initially written down on index cards and can be misinterpreted when passed among prehospital providers and used as a reference with documenting the electronic Patient Care Report.