Everything about Sample History totally explained
SAMPLE history is an
mnemonic acronym for
first responders to remember key questions for
patient assessment. The history is usually taken along with
vital signs. This is used for alert patients, but often much of this information can also be obtained from the family of an unresponsive patient.
Symptoms (and possibly Signs)
Symptoms are what the patient reports, as in "my head hurts." The primary reason a patient is being seen is termed the
Chief complaint. Signs are conditions the person rendering aid can
observe, such as seeing a
hematoma (bruise) or laceration, or
measure, such as collecting
vital signs with appropriate instruments. In a
SOAP note, symptoms are typically included with the rest of the SAMPLE history is the
Subjective section, while signs are included in the
Objective section.
Allergies
When asking a patient about allergies it's important to make the distinction between medical allergies and non-medical allergies. Some allergies that may not seem medical in nature are important however, such as
peanut allergies since many
asthma inhalers contain peanut by-products. Common abbreviations used when recording that a patient has no allergies include
NKA (No Known Allergies) and NKDA (No Known DRUG Allergies).
Medications
It is important to obtain a list of medications that a patient is currently taking, since those medications can indicate existing medical conditions a patient may not have reported, as well as ensuring that a conflicting medication isn't prescribed. An example of conflicting medications are
Sildenafil (Viagra) and
Nitroglycerine that can cause dangerous
vasodilation when taken together.
Pertinent Past History
A patient's medical history is a valuable tool in identifying or diagnosing a medical condition. For instance, if a patient has a history of
cardiac issues, a provider should suspect cardiac involvement when the patient complains of difficulty breathing.
Last Oral Intake
Knowing the last time a patient ate or drank, and what it was can help identify a patients condition. For instance with a
diabetic patient who is behaving erratically and states they haven't eaten in 8 hours, a provider should suspect
hypoglycemia. Likewise,
dehydration may be suspected if the patient reports poor fluid intake or dark
urine output.
Events leading up to (the emergency)
Having a clear history of symptom onset or how an injury occurred helps in identifying possible life-threatening conditions. For example, the fact that a patient experienced a
syncopal episode before a fall may be more important than a resultant bruise.
Further Information
Get more info on 'Sample History'.
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