Ulance 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 delive.
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How to fill out the WI F-47489 online
The WI F-47489 form, known as the EMS patient care worksheet, is essential for ambulance service providers to document patient care information during ambulance runs. This guide provides clear instructions on how to effectively fill out the form online, ensuring compliance with state regulations.
Follow the steps to complete the WI F-47489 form online.
- Click ‘Get Form’ button to access the form and open it for editing.
- Fill in the service name and run number at the top of the form. These fields identify the ambulance service and the specific run being documented.
- Record the incident date and the location of the incident. Accurate information here is vital for proper documentation.
- Add the en-route time, on-scene time, and leave scene time to provide a timeline of the ambulance run.
- Enter the patient’s name, date of birth, age, and sex. Ensure that this personal information is recorded legibly.
- Input the patient’s weight and address for identification and record-keeping purposes.
- Fill in the provider impression and time of onset to give context to the patient's condition.
- Document the nature of injury (NOI) or mechanism of injury (MOI) as relevant to the patient's situation.
- Record the physician's name and the Glasgow Coma Scale (GCS), as well as level of consciousness (LOC), indicating the patient's responsiveness.
- Complete the sections on respiratory rate, skin condition, and eye reactions by checking the appropriate boxes.
- Indicate whether oxygen was given and provide details about breath sounds and flow rate.
- List any allergies, medications, or past medical history relevant to the patient's care.
- Document the treatments administered, the response to those treatments, and any CPR details.
- Finally, review all entries for accuracy and clarity before saving the document. You can download, print, or share the completed form as necessary.
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F-47489 (08/2015). STATE OF WISCONSIN. Chapter DHS 110 Wis. Admin. Code. (608) 266-1568...
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