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Lesson 1: Initial Assessment
1-6
1-6. SAMPLE HISTORY
SAMPLE is an acronym used to help determine a patient's history of the current illness. SAMPLE history is very important in that will help you to determine some of the patient's key complaints. In the medical patient, a good history will help determine about 80 percent of the indications of what illness you are dealing with. During the SAMPLE history, it is also important to determine what allergies and medications the patient may have. This is a very important step in the treatment of any patient.
a. Signs and Symptoms. Signs are the things you can see about the patient's condition. Symptoms are what the patient tells you about his condition. Use OPQRST to help determine the patient's history.
(1) O -- Onset of the current condition, What were you doing when this happened? Did it come on suddenly? Did it come on slowly?
(2) P-- Provokes. What makes this condition better or worse? Did this get better when you rested? Took a medication?
(3) Q -- Quality. What is the quality of the pain? Have the patient describe in his own words what the pain feels like (stabbing, pressure, tearing, crushing, etc.). Try not to lead the patient by asking questions like, “Is it a stabbing pain?”
(4) R -- Radiation. Does the pain radiate? Or is it located in one specific area?
(5) S -- Severity. This is usually assessed by having the patient rate the pain on a scale of 1 to 10 with 10 being the worse. It is necessary to ask the patient about the worst pain they have ever felt to obtain a good basis for their pain threshold and previous pain exposure.
(6) T -- Time, How long has it been since the pain started?
b. Allergies. Is the patient allergic to medications, food, or other substances?
c. Medication. What medications is the patient currently taking? Make sure to ask about over-the-counter medications, herbal medications, and supplements that the patient may be taking.
d. Pertinent Past History. Does the patient have any pertinent medical history? Anything that the patient may feel is applicable to the current illness or injury?
e. Last Oral Intake. When did the patient last eat or drink?
f. Events Leading to the Injury or Illness. What events lead to this incident? What where you doing just before the event happened or started?
