History Taking Flashcards
What does S mean in SAMPLED
Signs and Symptoms
How to ask for Signs and Symptoms
“What’s going on today?”
What is the acronym for the general history taking?
SAMPLED
What is the A in SAMPLED
Allergies
How to ask about allergies?
“Are you allergic to anything?” If so, “what is your reaction?”
What is the M in SAMPLED
Medications
How to ask about Medications
“Are you on any medications?”
What is the P in SAMPLED
Past Medical History
How to ask about Past Medical History?
“Has this happened before” or “Do you suffer from any other medical conditions?”
What is the L in SAMPLED
Lists of Lasts
What to ask for Lists of Lasts?
Meal, GP, Bowel Movements, Menses…whatever is relevant to the situation
What is the E in SAMPLED
Events Leading Up
How to ask about Events Leading Up?
“What were you doing when it started?” “How long ago did it start?”
What is the D in SAMPLED
Advanced Health Directive
When to ask re Advanced Directive?
If it is relevant to the situation
What is the pain acronym?
OPQRST
What is the O in OPQRST?
Onset
What is the P in OPQRST?
Provocation
What is the Q in OPQRST
Quality
What is the R in OPQRST?
Radiation
What is the S in OPQRST?
Severity
What is the T in OPQRST?
Timing
How to ask for Onset?
“What were you doing when the pain began?”
How to ask for Provocation?
“What makes it better or worse?”
How to ask for Quality?
“How would you describe the pain?”
How to ask for Radiation?
“Does the pain radiate anywhere or does it stay in one place?”
How to ask for Severity?
“If you could rate the pain out of 10, 0 being no pain and 10 being the worst pain, what would it be?” “Has it always been this number or has it been getting better or worse over time?”
How to ask for Timing?
“How long ago did the pain start?” “How long ago was the last episode?” “How long does it usually last?”
What does SAMPLED mean?
Signs and Symptoms, Allergies, Medications, Past Medical History, Lists of Lasts, Events Leading Up, Directive
What does OPQRST mean?
Onset, Provocation, Quality, Radiation, Severity, Timing
