Free Emergency Medical Services (EMS) Patient Care Worksheet, DPH 7489 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7489 (04/08)

STATE OF WISCONSIN Chapter HFS110 Wis. Admin. Code (608) 266-1568

EMERGENCY MEDICAL SERVICES (EMS) PATIENT CARE WORKSHEET
This form is for use by ambulance service providers who are unable to immediately comply with Chapters HFS 110, 111, 112 and 113, Wis. Admin. Code as they apply to documentation of ambulance runs by completing and providing patient care information to the receiving facility when the patient is delivered to the facility. Per the above administrative rules, this form becomes 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 the receiving facility when the patient is delivered. This form does not constitute the official ambulance run report / patient care report.

Ambulance Service: Incident Date: Patient Name: DOB PatientAddress: Chief Complaint: Physician: NOI / MOI: GCS: LOC: Time Eyes 4-1 Alert X
(Check one)

Run Number: Incident Location:

Age:

Sex:

Male

Female

Weight:

Speech 5-1 1 2 3

Motor 6-1
(Check all that apply)

Total Respond to verbal Respond to pain Unresponsive Oximetry Glucometer EKG Monitor

BP

Pulse Rate / Quality

Respiratory Rate

Skin: Eyes:

(Check all that apply) (Check all that apply)

Warm PERRL

Dry

Moist

Cold Dilated

Flush Non-reactive Mask

Pale

Constricted

O2 Given: Allergies: Medications:

Yes

No

Rate of flow:

(Check one)

cannula

BVM

Last Oral Intake:
(Check all that apply)

Past Medical History Other Treatment:

Cardiac

CHF

Hypertension

Seizure

Diabetes

COPD

Asthma

Response to Treatment: CPR: Yes No Yes Time Started: No Rate Respirations? Defib/Shock: Yes No Yes Rate No

Return of Pulse? Squad Member(s):

THIS FORM DOES NOT REPLACE THE OFFICIAL ABULANCE RUN REPORT OR THE PATIENT CARE REPORT