SAMPLE and OPQRST¶
Category: Concepts Sources: raw/supplemental/patient-assessment-sequence.md, raw/nremt/psychomotor-skills.md Last updated: 2026-04-05
Overview¶
SAMPLE and OPQRST are the two standard frameworks for prehospital history taking. SAMPLE gathers the patient's background — their medical context. OPQRST characterizes the current complaint in detail. Together they provide the full picture of why a patient called 911 and what to do about it.
Both mnemonics are used in the history-taking step, which follows the primary-assessment. Findings from SAMPLE and OPQRST directly drive medication and treatment decisions — this is not just documentation. The allergy field can contraindicate aspirin. The medications field can identify a patient on anticoagulants. The events field can identify a syncope that preceded the trauma. Every letter has clinical consequences.
SAMPLE¶
SAMPLE is used on every patient, every call. It gathers the six categories of background information that define the patient's medical situation.
S — Signs and Symptoms¶
Signs are objective findings you observe or measure (pale skin, tachycardia, diaphoresis, vomiting). Symptoms are subjective complaints the patient reports (chest pain, nausea, headache, weakness).
Both are captured here. Document both the chief complaint ("I have chest pain") and your objective findings ("diaphoretic, splinting left arm against chest, HR 110").
Clinical use: Signs and symptoms determine your initial differential diagnosis and which direction the rest of the assessment should go. Crushing chest pain with diaphoresis → ACS differential → OPQRST + aspirin consideration. Sudden one-sided weakness + slurred speech → stroke differential → Cincinnati screen.
A — Allergies¶
What to ask: "Are you allergic to any medications? Any foods? Latex? Insects?" Follow up: "What happens when you take/touch/eat that?"
Document both the allergen AND the reaction. "Allergic to penicillin — rash" is very different from "Allergic to penicillin — throat closes, requires EpiPen." The first is a drug allergy; the second is anaphylaxis history.
Clinical use: - Aspirin/NSAID allergy → contraindication to aspirin for ACS. Do not administer. - Bee sting allergy with known anaphylaxis history → patient likely has their own epinephrine auto-injector; find it. - Latex allergy → affects your PPE choices and equipment used. - Any allergy history + exposure to possible allergen + systemic symptoms → consider anaphylaxis protocol. See epinephrine-auto-injector.
M — Medications¶
What to ask: "What medications do you take? Prescriptions? Over-the-counter? Vitamins or supplements? Any medications you've taken today?"
Ask about timing and dose for the current complaint (e.g., "Did you take your blood pressure medication this morning?").
Clinical use:
| Medication Found | Clinical Implication |
|---|---|
| Nitroglycerin | Known cardiac history; may repeat dose for chest pain (per protocol) |
| Beta-blockers (metoprolol, atenolol) | Will blunt tachycardia — cannot use HR as reliable shock indicator |
| Anticoagulants (warfarin, Xarelto, Eliquis) | Trauma patients bleed more; brain bleeds are more dangerous |
| Insulin | Known diabetic; hypoglycemia risk in altered mental status |
| Aspirin (already took today) | Contraindication to repeat aspirin dose for ACS |
| Epinephrine auto-injector | Patient has known severe allergy history |
| Albuterol inhaler | Known asthma or COPD |
| Seizure medications (Keppra, Dilantin) | Seizure history; check compliance (missed doses → breakthrough seizure) |
P — Past Medical History¶
What to ask: "Have you had any major medical conditions? Previous hospitalizations? Surgeries? Similar episodes in the past?"
Document all relevant prior diagnoses and any procedures (bypass surgery, pacemaker, dialysis, prior spinal surgery, organ transplant).
Clinical use: A history of previous cardiac events or known coronary disease dramatically raises the ACS probability for chest pain. A history of COPD changes oxygen therapy targeting (SpO2 88–92%, not ≥95%). A diabetic history makes hypoglycemia the top consideration for altered mental status. Prior spinal surgery affects spinal immobilization technique.
L — Last Oral Intake¶
What to ask: "When did you last eat or drink anything? What was it?"
For pediatric patients, also ask about last wet diaper (dehydration screen). For pregnant patients, this is part of the pre-delivery assessment.
Clinical use: - Pre-operative concern: If the patient is going to surgery, the anesthesiologist needs to know the last intake — aspiration risk from a full stomach under anesthesia is life-threatening. "Last ate 2 hours ago" changes the OR plan. - Diabetic patients: "Took my insulin at 7 AM and forgot to eat" explains hypoglycemia. "Ate a large meal 1 hour ago" with elevated BGL points toward hyperglycemia. - Pediatric patients: Vomiting and diarrhea with poor oral intake = dehydration risk. Affects fluid resuscitation decisions. - Substance-related: "Last drink 30 minutes ago" or "Used heroin 4 hours ago" informs the clinical picture.
E — Events Leading to Incident¶
What to ask: "What were you doing when this started? Did anything happen right before this? Is there anything you think caused this?"
Capture the sequence of events, not just the moment of the call.
Clinical use: - Chest pain that started during exertion (climbing stairs, mowing lawn) → higher ACS probability than pain at rest - Syncope before a fall → this may be a medical emergency, not just a trauma case; treat both mechanisms - "I was fine and then suddenly..." → sudden onset suggests vascular event (stroke, PE, aortic dissection, MI) - "Gradually got worse over 3 days" → infection, inflammation, or progressive medical condition - Witnessed events: bystanders tell you a patient had a seizure before they were found face-down → changes your assessment priority entirely
OPQRST¶
OPQRST builds a detailed picture of the current symptomatic complaint — most commonly pain, but also shortness of breath, nausea, or any specific symptom. OPQRST is most valuable when a patient has a primary complaint that needs characterization. It is used alongside SAMPLE, not instead of it.
O — Onset¶
What to ask: "When did this start? Did it come on suddenly or gradually?"
Clinical use: - Sudden onset chest pain → dissecting aortic aneurysm ("tearing" quality), PE, pneumothorax - Sudden onset headache → subarachnoid hemorrhage ("thunderclap" headache = worst headache of my life) - Sudden onset weakness/facial droop → stroke - Gradual onset → infection, muscle strain, developing medical condition - After a meal → GI pathology, peptic ulcer, gallbladder disease - At rest vs. exertion → angina vs. ACS (stable angina at exertion; unstable angina or MI can occur at rest)
P — Provocation / Palliation¶
What to ask: "What makes it worse? What makes it better? Does anything change the pain?"
Clinical use: - Pain worsened by palpation → superficial or musculoskeletal; true cardiac pain is typically not reproducible by pressing on the chest - Pain relieved by nitroglycerin → suggests coronary vasospasm or ischemia (consistent with ACS — though relief alone does not confirm ACS) - Pain worsened by breathing (pleuritic pain) → pericarditis, pleuritis, rib fracture, PE - Pain relieved by leaning forward → pericarditis (classic finding) - Abdominal pain worsened by movement → peritoneal irritation (guarding, rigidity = surgical abdomen) - Pain unchanged by anything → visceral pain (organ pain; not position-dependent)
Q — Quality¶
What to ask: "How would you describe it? What does it feel like?"
Do not lead the patient — ask them to describe in their own words first, then offer options if needed.
Clinical use:
| Quality Descriptor | Suggests |
|---|---|
| Pressure, crushing, squeezing, heavy | Myocardial ischemia (ACS) |
| Sharp, stabbing, knife-like | Pleuritic pain, pericarditis, pneumothorax |
| Tearing, ripping | Aortic dissection |
| Burning | GERD, esophageal spasm, or cardiac (sometimes) |
| Dull, aching | Muscle strain, referred visceral pain |
| Cramping, colicky | GI or urologic pathology (comes in waves) |
| Throbbing | Vascular or migraine etiology |
Note: "Burning" chest pain does not rule out ACS — a significant percentage of ACS patients describe their pain as burning or indigestion.
R — Radiation¶
What to ask: "Does the pain go anywhere else? Does it travel or spread?"
Clinical use: - Left arm/shoulder radiation → classic ACS (especially left medial arm, down to 4th/5th digits) - Jaw or neck radiation → ACS - Back radiation → aortic aneurysm or dissection, MI (posterior wall), pyelonephritis (flank radiation) - Shoulder radiation (especially left) → diaphragmatic irritation from abdominal hemorrhage (Kehr's sign — spleen injury) - Radiation to groin or scrotum → kidney stone (ureterolithiasis) - No radiation → not specific; many serious conditions don't radiate
S — Severity¶
What to ask: "On a scale of 1 to 10, with 10 being the worst pain you've ever had, where would you rate this?"
Document the number, the patient's comparison ("worse than my previous MI"), and any functional limitation ("couldn't walk to the phone").
Clinical use: - Severity 10/10 "worst pain of my life" → subarachnoid hemorrhage, aortic dissection, testicular torsion - Severity trending: a patient who was 8/10 and is now 10/10 after nitroglycerin is not responding to treatment — escalate - Severity does not correlate cleanly with injury severity — diabetics and elderly patients often have MI with minimal pain (2–3/10 or no pain at all) - Pain out of proportion to injury → suspect compartment syndrome, ischemic bowel, necrotizing fasciitis
T — Time¶
What to ask: "How long has this been going on? Is it constant or does it come and go? Getting better, worse, or staying the same?"
Clinical use: - Stroke: "Last known well" time is derived from the T component — when was the patient last at their neurological baseline? This is the clock that determines tPA eligibility. See cincinnati-stroke-scale. - Cardiac arrest: Time down is critical for resuscitation decision-making and prognostication. - Intermittent pain → possible angina, GI colic, or migraine - Constant and worsening → more concerning than intermittent; organ damage is ongoing - Duration <1 hour → more acute and potentially reversible - Symptom onset before the call — many patients wait. A patient who says their chest pain started "a little while ago" may mean 6 hours ago. Ask specifically.
When to Use Which¶
| Situation | SAMPLE | OPQRST |
|---|---|---|
| Every patient | Always | Only if complaint needs characterization |
| Unresponsive patient | From bystanders/environment | Not applicable |
| Trauma patient | Always | For pain complaints |
| Medical patient | Always | Always, for primary complaint |
| Minor complaint (abrasion, twisted ankle) | Always | Brief; focused on current complaint |
| Multiple complaints | Always | For each significant complaint |
OPQRST is most valuable for: Chest pain, shortness of breath, abdominal pain, headache, back pain, neurological symptoms, any pain that needs characterization for triage or medication decisions.
OPQRST is limited for: Unresponsive patients (they can't answer), patients with language barriers (adapt as able), patients with cognitive impairment (ask caregivers or use observable components).
How History Drives Treatment Decisions¶
SAMPLE + OPQRST are not just documentation — they determine what you do next.
| History Finding | Treatment Consequence |
|---|---|
| A: Aspirin allergy | Do NOT give aspirin for ACS |
| M: Already took aspirin today | Do NOT repeat aspirin — stacking risk |
| M: Uses prescribed nitroglycerin | May assist patient with their own NTG per protocol |
| M: Insulin-dependent diabetic + AMS | Check BGL → oral glucose if conscious and able to swallow |
| M: Beta-blocker | Do not use HR alone to assess shock — BP + skin signs are more reliable |
| P: COPD | Titrate O2 to SpO2 88–92%; avoid hyperoxia |
| A: Bee sting allergy + exposure + systemic symptoms | Epinephrine auto-injector protocol |
| E: Syncope before fall | Treat medical cause AND trauma mechanism |
| OPQRST-Q: Crushing chest pressure + S: 8/10 + R: Left arm | High ACS suspicion → aspirin if no contraindications |
| OPQRST-T: Last known well 45 min ago + facial droop | Stroke → Cincinnati screen → Stroke Center transport |
Common Mistakes¶
- Skipping L (last oral intake) — Students find this the least medically interesting letter and rush past it. But it's critical before surgery, for hypoglycemia assessment, and for dehydration.
- Asking leading questions — "Is it a crushing pain?" instead of "How would you describe the pain?" leads the patient. Crushing pain is the NREMT-correct ACS descriptor, and students sometimes fish for it. Let the patient describe first.
- Using "onset" and "time" as the same thing — Onset is how it started (sudden vs. gradual). Time is how long it has been going on and whether it's changing. A headache that started suddenly 3 hours ago is both sudden onset (O) and 3 hours in duration (T).
- Not documenting the allergic reaction, only the allergen — "Penicillin allergy" is incomplete. "Penicillin — throat swelling, hospitalized" is a complete allergy entry that changes how an ER approaches this patient.
- Skipping OPQRST because the patient seems fine — A patient who walked to you and is A&Ox4 still deserves a complete OPQRST for their complaint. "Seems fine" is not an assessment finding.
- Not using bystanders for unresponsive patients — Bystanders are your SAMPLE source when the patient can't speak. "She was fine watching TV and then just fell asleep and we couldn't wake her up" (E) + "She's a diabetic" (P) + "She took her insulin this morning" (M) gives you a near-complete picture.
NM Protocol Notes¶
- NM EMS documentation requires SAMPLE and chief complaint on the PCR for every call.
- OPQRST is specifically requested in protocol narrative for chest pain, stroke, and respiratory distress calls.
- Medication history is required — especially anticoagulant use for stroke patients (affects tPA eligibility).
- For ACS patients, SAMPLE-A (aspirin allergy check) is a protocol-required step before aspirin administration. See aspirin.
- For anaphylaxis, SAMPLE-A and SAMPLE-E (what was the patient exposed to?) determine trigger identification and future risk.
NREMT Relevance¶
Both SAMPLE and OPQRST appear on the cognitive exam and in the Patient Assessment/Management skill stations:
- SAMPLE: All 6 letters tested. Know what each stands for and what clinical decisions each letter drives.
- OPQRST: All 6 letters tested. Common cognitive exam question: a patient describes crushing chest pressure radiating to the left arm — which mnemonic component is "radiating to the left arm"? (R — Radiation)
- Medical skill station: examiners look for all 6 SAMPLE components and full OPQRST for the presenting complaint
- Common NREMT miss: forgetting L (last oral intake) or E (events leading to the incident)
- Know that OPQRST is supplemental to SAMPLE — you can have SAMPLE without OPQRST (asymptomatic or unresponsive patient), but never OPQRST without SAMPLE
Related¶
- history-taking — full assessment context for SAMPLE and OPQRST; when to gather from bystanders
- primary-assessment — precedes history taking; AVPU and life threats addressed first
- aspirin — medication trigger: ACS chest pain + no aspirin allergy + no prior dose today
- oral-glucose — medication trigger: AMS + known diabetic in SAMPLE + able to swallow
- epinephrine-auto-injector — medication trigger: allergic reaction + SAMPLE-A positive + systemic signs
- six-rights — every medication triggered by SAMPLE findings requires the 6 Rights before administration
- cincinnati-stroke-scale — stroke screen that uses OPQRST-T (time/last known well)
Sources¶
raw/supplemental/patient-assessment-sequence.md— Section 3: History Takingraw/nremt/psychomotor-skills.md— Patient Assessment/Management (Medical)