THIS FORM DOES NOT REPLACE THE OFFICIAL PATIENT CARE REPORT
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-47489 (08/2015)
STATE OF WISCONSIN
Chapter DHS 110 Wis. Admin. Code
(608) 266-1568
EMS PATIENT CARE WORKSHEET
This form is for use by ambulance service providers to comply with Chapter DHS 110, Wis. Admin. Code as it applies to documentation
of ambulance runs by completing and providing patient care information to the receiving facility when the patient is delivered to the
facility. This form is not intended to become part of the patient’s medical record.
INSTRUCTIONS: Print legibly. Complete all sections of this worksheet. A copy of this worksheet or the ambulance run report must be
completed and left with every patient delivered to a receiving facility.
Service Name: Run Number:
Incident Date: Incident Location:
En-route Time: On-Scene Time: Leave Scene Time:
Patient Name:
DOB: Age: Sex: Male Female Weight:
Patient Address:
Provider Impression: Time of Onset:
NOI / MOI: Physician:
GCS: Eyes (4-1) = Verbal (5-1) = Motor (6-1) = Total (15-3) =
LOC: Alert Verbal Pain Unresponsive
Skin: (Check all that apply) Warm Dry Moist Cold Flush Pale
Eyes: (Check all that apply) PERRL Constricted Dilated Non-reactive
O2 Given: Yes No Rate of Flow: (Check one) Mask Cannula BVM Other
Breath Sounds: Clear Wet Absent Stroke Scale: (Check if present) Facial Arm Speech
Droop Drift Impaired
Allergies: Last Oral Intake: Last Known Well:
Medications:
Past Medical Hx:
(Check all that apply) Cardiac CHF Hypertension Seizure Diabetes COPD Asthma
Other:
Treatments:
Response:
CPR: Yes No Time Started: _______________ Defib/Shock: Yes No Airway: Yes No
Return of Pulse? Yes No Rate: Respirations? Yes No Rate:
Squad Members:
