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History Taking

Category: Patient Assessment Sources: raw/supplemental/patient-assessment-sequence.md Last updated: 2026-04-03

Overview

History taking is the third step in patient assessment, conducted after primary-assessment has addressed life threats. The goal is to gather subjective information — what the patient (or bystanders) can tell you — to understand the nature of the problem and guide the secondary-assessment. Two core mnemonics structure this: SAMPLE and OPQRST.

Key Points

SAMPLE History

Used for every patient, every time.

  • S — Signs and symptoms (what is the patient experiencing right now?)
  • A — Allergies (medications, environmental, food — ask specifically about drugs)
  • M — Medications (prescription, OTC, herbal, recreational; ask about last dose)
  • P — Past medical history (relevant prior conditions, surgeries, hospitalizations)
  • L — Last oral intake (when did they last eat or drink? Critical for surgery and airway management)
  • E — Events leading to incident (what was happening when this started? What were they doing?)

OPQRST (for pain or specific complaint)

Builds a detailed picture of any symptomatic complaint, especially pain.

  • O — Onset (sudden vs gradual? What were you doing when it started?)
  • P — Provocation / Palliation (what makes it worse? what makes it better?)
  • Q — Quality (sharp, dull, pressure, crushing, tearing, burning?)
  • R — Radiation (does the pain/symptom go anywhere else?)
  • S — Severity (1–10 pain scale; how does it compare to other pain you've had?)
  • T — Time (how long has it been present? Constant or intermittent? Getting better or worse?)

Assessment Relevance

History drives diagnosis in the field. A patient with crushing chest pain radiating to the left arm, diaphoresis, and a history of cardiac disease points strongly toward ACS — which triggers aspirin administration consideration. A diabetic patient found altered points toward hypoglycemia — which points toward oral-glucose. A patient with sudden-onset urticaria and throat tightness after a bee sting points toward anaphylaxis — which points toward epinephrine-auto-injector.

For unconscious or unresponsive patients, gather history from: - Bystanders or family - Medical alert jewelry (bracelets, tags) - Medications found on scene - Scene environment (pill bottles, drug paraphernalia, smell of alcohol)

For responsive patients, let the patient tell the story — avoid leading questions when possible.

Procedures

History taking is not a physical procedure but follows a structured conversational sequence:

  1. Introduce yourself and get consent.
  2. Ask open-ended chief complaint question: "What's going on today?" or "What brought you to call 911?"
  3. Work through OPQRST for the chief complaint.
  4. Work through SAMPLE systematically — don't skip letters under pressure.
  5. Document findings — exact quotes from patients are valuable.
  6. Share relevant findings with receiving facility during hand-off report.

NM Protocol Notes

  • NM EMS documentation requires SAMPLE and chief complaint be captured on the patient care report (PCR).
  • Medical direction may request OPQRST for ALS-level calls or specific chief complaints (chest pain, SOB, neurological symptoms).
  • For altered mental status in diabetic patients, SAMPLE history (especially medications and last intake) directly drives the decision to administer oral-glucose.

NREMT Relevance

History taking is embedded in both Trauma and Medical patient assessment skill stations: - Medical: full SAMPLE + OPQRST expected - Trauma: SAMPLE required; OPQRST used for pain complaints - Examiners look for all 6 SAMPLE components being addressed - Common miss: forgetting "L" (last oral intake) or "E" (events) - Unresponsive patient: expect to be asked how you would gather history — bystanders, scene clues, medic alert tags

  • primary-assessment — precedes history taking; life threats addressed first
  • secondary-assessment — follows history; history findings focus the physical exam
  • scene-size-up — MOI vs NOI determination here shapes which history elements are most critical
  • aspirin — medication trigger: chest pain history + SAMPLE pointing to ACS
  • oral-glucose — medication trigger: altered mental status + known diabetic in SAMPLE
  • epinephrine-auto-injector — medication trigger: allergic reaction history + SAMPLE
  • reassessment — trending changes in history and vitals over time

Sources

  • raw/supplemental/patient-assessment-sequence.md — Section 3: History Taking