SAMPLE history

__NOTOC__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.

*S: Signs and Symptoms
*A: Allergies
*M: Medications
*P: Pertinent past history and Pregnancy
*L: Last oral intake (or Last ins and outs)
*E: Events leading up to (the emergency).

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 "S"ubjective section, while signs are included in the "O"bjective section.

Allergies

When asking a patient about allergies it is 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.Fact|date=April 2008 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. Pregnancy is another concern in women of child-bearing age. First, this limits diagnostic and treatment options (no X-rays or certain medications). Secondly, in women with abdominal pain, a beta-hCG pregnancy test is given to rule out the potentially fatal misdiagnosis of ruptured ectopic pregnancy.

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.

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References