EMT- SAMPLE History during a Patient Assessment

A “SAMPLE” history is a mnemonic used in the medical field, and is a useful tool that is easy to remember for EMTs. The SAMPLE history is usually gathered during the secondary assessment during EMT school, after you have managed the patient’s ABCs (Airway, Breathing, Circulation), after you have managed any immediate life-threats during your primary assessment. Here is what SAMPLE stands for:

S- Signs/Symptoms
A- Allergies
M- Medications
P- Pertinent Medical History
L- Last Oral Intake
E- Events Leading up to Illness/Injury

Signs/Symptoms

Signs are what you can see (objective), and symptoms are what the patient is feeling (subjective). An Example of Signs are: Sweating, visible blood, vomit on the floor, etc… An Example of Symptoms are: Nausea, Headache, abdominal Pain, etc…

Even though the SAMPLE history is gathered during the secondary assessment during EMT school, you will obviously gather some of the Signs/Symptoms when you first arrive on scene.

Example “Signs/Symptoms” Questions:

What is Bothering you today?
What made you call 911 today?
What Symptoms are you feeling? You may need to ask close ended questions

Allergies

Asking a patient if they have any allergies is very important during the patient assessment. The patient may need medication(s) during their treatment, and they may not be able to answer this question for long if they lose consciousness. The hospital you bring the patient to may not have any medical records for the patient, and will not know what the patient is allergic to if the patient can no longer answer this question when they arrive.

This question may also help indicate what is going on with the patient during a respiratory emergency (possible severe allergic reaction).

Example “Allergies” Questions:

Do you have any allergies to Medications
Are you allergic to anything else? (Bees, Food, etc…)

Medications

Ask the patient if they currently take any medications (prescription and OTC). During EMT school, your patient will likely be taking only a few medications.

When you are working on an Ambulance, many patients have a long list of medications that they are taking. If you are lucky, they will have a list of their medications written out for you that you can bring with you to the hospital. It may be best to put all of their medications into a bag and bring them with you to the hospital to save time.

If you are conducting a patient assessment, pay attention to what medications they tell you that they take. If they are having chest pain and currently take Nitroglycerin, ask them if they had taken any prior to your arrival (they may have already taken their maximum dose). Do this for any medication you are going to administer to make sure they have not reached their maximum dosage.

Pay attention to what medications you are going to give a patient and what their allergies are. Ask them what their allergies are before you ask for their medications.

Also if you are going to give Nitro, ask specifically if they have taken any Erectile Dysfunction Medications in the last 3 days (some of the medications last up to 3 days). I do this even if they don’t mention this while you are asking for their medications. Many patients do not want to tell you that they are taking E.D. medications; if you ask them this question directly, they are more likely to answer honestly because they realize you are asking it for a reason (emphasize its importance).

Example “Medications” Questions:

Are you taking any prescription medications?
Are you taking any over-the-counter (otc) medications?
Have you taken any Erectile Dysfunction Medications in the last 3 days? (chest pain patients)

Pertinent Medical History

Try to gather the best medical history from the patient that you can. You are looking for a Significant medical history here (not if they sprained their ankle 20 years ago). “Pertinent” means relevant to their current condition, but I recommend you try to gather their “significant” medical history (it is possible that you will not know what is pertinent). Don’t expect the patient to know what is significant or not, and be ready to ask closed ended questions.

For example, I recently hooked up a patient with a heart rate of 140 up to my cardiac monitor, and the patient was in A-fib (atrial Fibrillation); I asked the patient if he “had a history of A-Fib”, and he said “No”. I then asked him if he had “any heart problems”, and he said “no”. I then asked him if he had any “history of an irregular heartbeat”, and he said “yes”. The point of this is that many patients don’t know what their condition is called, or are very knowledgeable about it.

If you ask a question if they have any “significant” medical history, or “pertinent” medical history, many times they will tell you no. Be Prepared to ask “close ended” questions to gather their pertinent history. During your EMT exam, when you ask for the “pertinent history”, the person testing you will tell you their whole medical history when you ask, but this is not what happens in the real world. Many times, a patient’s medications will provide better clues to the patient’s medical history than the patient can tell you.

Example “Pertinent Medical History” Questions:

Can you tell me your medical history?
Do you have any serious medical problems?
Do you have any problems with your heart?
Do you have any problems with your lungs?
Do you have any history of an “irregular” heartbeat?
Do you have Diabetes?
Do you have a history of Hypertension?
Do you have a history of COPD?
Do you have a history of CHF?
Have you ever had a Stroke? TIA?
Have you ever had a Heart Attack?
Surgical History?
Have you been hospitalized recently?

Last Oral Intake

Ask the patient the last thing they ate/drank. This may provide clues to their illness. For example, someone with chest pain that just ate some spicy food may be experiencing heartburn. Someone with abdominal pain that just ate a fatty meal may be having gallbladder issues.

The Last Oral intake can also provide you clues for patients who have food poisoning, an allergic reaction, or that are hypotensive (inadequate hydration can lead to hypotension).

If the patient has not been eating or drinking much because they are nauseated, this can lead to further problems. Also ask the patient about their urinating/bowel movements. Nausea/Vomiting/Diarrhea can lead to dehydration. If the person has not been urinating, that can indicate dehydration as well.

Example “Last Oral Intake” Questions:

What was the Last thing you ate?
What was the Last thing you drank?
Have you been eating and/or drinking adequately the last few days?

Events Leading up to Illness/Injury

It is important to know what the patient was doing leading up to their illness or injury.

When a patient is having chest pain, you should ask them what they were doing when the pain started; if they were active at this time (example: running), it is more likely to be cardiac related then if they were inactive (watching t.v.).

If they are having pain anywhere, (example: pain in their right leg” it will help you provide clues to why the pain started. If they are having pain after doing a leg work-out, it is probably muscle pain or an injury. If they were just sitting on the couch, and had not had an injury, you may suspect a medical reason for the pain (possible DVT, etc…).

Example “Events Leading to Illness/Injury” Questions:

What were you doing when the Pain/Symptoms Started?
When did the Illness/Injury Start?

Conclusion

Try to gather a SAMPLE history for every patient that you assess (unless you cannot move past the ABCs because they are not intact). As a first responder to the patient, you may be the only person that has the opportunity to ask the patient these questions (if they lose consciousness). This information can be very valuable to an ALS intercept, or the receiving hospital. If you liked this post, please check out some of my other EMS posts above. Thanks for reading!