Objective: The aim of this study is to analyze the content of the run sheets of patients brought by EMS with acute ischemic stroke. Background: Prehospital care of acute stroke is now more important than ever after the recent endovascular trials showed benefit of mechanical thrombectomy in large vessel occlusion (LVO) stroke. To maximize our utilization of emergency medical services (EMS) we need to study our current resources. Design/Methods: Institutional Get With The Guidelines (GWTG) database was used to identify ischemic stroke patients. We retrospectively reviewed the EMS run sheets, abstracted the examination findings, and correlated these findings with the initial National Institute Stroke Scale (NIHSS) score upon arrival to the emergency room (ER) and IV alteplase utilization. Results: There were 706 patients (age 69±15 years; 45% were women). EMS patients (n=477; 63.3%) were significantly older (72±14.9 vs 64±14 years; p<0.0001), had a significantly higher median (interquartile rage [IQR]) initial NIHSS (6 [2–14] vs 2 [0–43]; p<0.0001), faster median time from onset to ER (106 (54–573] vs 697 [221–2073] minutes; p<0.0001), and had higher rate of IV alteplase administration (17% vs 2.4%; p<0.0001) and mechanical thrombectomy (8.3% vs 0; p<0.0001). Level of consciousness was assessed in 336 patients (81%), focal extremity weakness was reported in (39.8%), facial weakness (26.6%), and aphasia (9.2%). Non-specific terms were used frequently: slurred speech (25.5%), ‘altered mental state’ (23.5%%), generalized weakness (14.5%). Extinction, visual field cut, and ataxia were never reported. Aphasia, facial weakness, focal weakness, diplopia/gaze deviation, and non-specific mental state change were associated with high NIHSS and high IV alteplase utilization. Conclusions: Patients with acute stroke transported by EMS have better quality metrics and higher chance of receiving acute treatment. EMS documented assessment allows for the diagnosis or stroke in general but cannot identify LVO because the assessment of cortical signs is very limited.