Skip to main content
Corporate

September 12, 2019 - Revised: 03.06.20

Ambulance Crew Member Signatures

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.

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.”

However, the crew member who is the designated driver on the call and not the primary caregiver, is not required to sign the PCR.  While you were still involved in the assessment and, to some extent, are responsible for the care of the patient, CGS will not deny a service when the driver’s signature is not present on the documentation.

A good “checks and balance” would be the signature of all crew members involved in the transport of a patient as having more than one set of eyes on the report helps tremendously in reducing errors and omissions in documentation.

Remember:

  • You’re providing professional medical care to the patient!  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.
    1. Electronic signatures will suffice if 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.
    2. 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.

The bottom line is that legibly signing your patient care reports, including your printed name and credentials, is a fundamental standard of care

References:

Was this page helpful? YES NO


26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved