Understanding The SAMPLE History

The SAMPLE history usually comes up in the first few weeks of EMT class. It’s such a widely accepted standard that it appears in the National Registry medical and trauma skills station as well as the EMT National Standard Curriculum. As far as subjective patient history’s go…SAMPLE is the gold standard.

Like anything else in medicine, widespread utilization also comes with widespread misunderstanding. The SAMPLE history is an educational gold standard for a reason. It’s a very effective tool for remembering the major components of a medical history.  It’s also often misused and highly inadequate when taught and utilized at face value.

Let’s review the SAMPLE history and talk a bit about how to use it correctly to get all the juicy bits of medical history that you need when treating our patient.

First, to make sure we’re all on the same page, let’s review the SAMPLE acronym. SAMPLE is a six part subjective assessment that covers a good deal of critical information that is typically gathered in a basic subjective patient assessment. To review the difference between subjective and objective assessments, check out the SOAP reporting format. SAMPLE stands for:

S – Symptoms (Signs are important but they are objective.)

A – Allergies

M – Medications

P – Past Medical History

L – Last Oral Intake (Sometimes also Last Menstrual Cycle.)

E – Events Leading Up To Present Illness / Injury

That’s pretty straight forward. But let’s dive a little deeper. The first thing I’d like to emphasize before we jump into the questions in a little more detail is this – a SAMPLE history is not over in six questions. They are never complete in six questions.

I emphasize this because that isn’t the way we typically teach it in EMT class. You run your scenario and you say to your skills instructor, “I’d like to know about her signs and symptoms, allergies, medications, history, oral intake and prior events. And then the instructor dutifully rattles off a list of information. Do this over and over again and you may get the idea that your SAMPLE history will be six questions long and take approximately 2 minutes to complete.

In truth, the SAMPLE history, when done correctly, is a time consuming and detailed interview that may begin in the first few moments of patient care and continue until your walking through the doors at the emergency room. Good SAMPLE histories can be disorderly and divergent. They go off on tangents. They explore deeper than the basic questions. They encourage the patient to talk and elaborate (when the patient is able).

If you remember only one thing about this post when you show up to work tomorrow, remember this, a good SAMPLE history will take more than six questions to finish. If you accept the first detail that your patient volunteer and then move on to the next subject, you’re going to miss a bunch of stuff.

Let’s look at each question with a bit more detail. I’d like to identify many of the common ways that we can diverge from the basic question to get a better picture of our patient’s predicament.

Symptoms (And occasionally signs)

While the patient may report physical signs as their subjective complaints (i.e. My fingernails turned blue. I can’t move my legs.) for the most part, reported complaints are subjective in nature. I like to start my SAMPLE with a broad and open ended question like, “So what’s going on today?” or “Can you tell me what’s been bothering you today?”

For our injury patients, questions like, “What happened?” or the slightly less broad but time saving, “What exactly happened to you?” might be good starting points. Be ready to ask follow up and exploratory questions like, “What else happened?” or “What did you feel then?”

The good opening symptom question will encourage the patient to tell us, in their own words, what they are feeling and what physically happened to them. We may need to keep the patient from veering off to far into the events leading up to the illness or injury. If you feel like you have a handle on their specific complaints, let them diverge. You can always come back. But don’t be afraid to pull them back on topic until you have a good understanding of what they are experiencing right now.

Try to avoid long lists of closed ended questions like, “Do you feel chest pain?”, “Do you feel shortness of breath?”, “Do you feel dizzy?” You can spend a long time working through symptom checklists and never come anywhere near the true patient complaint. An earnest, “Tell me what you are feeling?” can get you to the point so much faster than a long list of closed ended questions.

Also know that you will frequently end up diverging into your full QPQRST before you move off of the “S” in SAMPLE. That’s OK. Go where you need to go. Another hint on OPQRST…it isn’t six questions either.

Allergies

“Have you ever had an allergic reaction?” is a good place to start with the allergies portion of your SAMPLE. This will often prompt the patient to begin by telling you about their most significant allergic episode. This may be medical or environmental. We often start with a medications specific question. I don’t think this is the best way to go. I’d prefer to start with the most significant allergy.

This also avoids glossing over significant allergies to bites, stings, latex, food or other, non-medication related stimuli. I also follow up with, “What other things have you been allergic too?” Keep going until the patient runs out of answers.

Medications

I know there are some providers who will probably disagree with me on this point but, for our patients with extensive medication lists, I don’t spend a bunch of time trying to get them to name all of their medications. If they can rattle off the list, I’ll certainly write it down, but few people who take more than three medications can list them off.

This is especially true for our patients who have their medications nearby. If we’ve found a big pile of medications, I’ll probably ask something like, “Are these all of your medications?” or “Where else do you keep your medications?” and then be done with it. I’d rather read the medication list and jump right into medical history instead.

There are a few more vital questions to ask before you move off of the medication list. One is, “Are you taking all of your medications?” I’ll usually follow this up with a few questions about how often the patient takes a prescription medication. “Mrs. Goldberg, how often are you supposed to take your Lisinopril?” The goal is to get an idea of how well versed the patient is in their medication dosing and frequency. If the patient struggles with the follow up questions, we need to consider that non-compliance (not taking prescribed meds as prescribed) may be an issue.

Another way to root out possible medication non-compliance is to ask, “Have you stopped taking any of your medications? You will often find that, due to unwanted side effects, many patients simply quit taking medicine that they have been prescribed. Not the medicines that have been discontinued and explore why the patient quit taking the medicine.

It’s also worthwhile to ask if there are any non-prescription medications that the patient takes. This includes over the counter medications, herbal medicines and alternative medications. You also want to ask about drugs and alcohol consumption. This is a good place to include that question.

Past Medical History

Once you have a good idea what medicines, the next are to move into is an exploration of why those medications are consumed. If I already have a makeshift list of medical ailments I may start by reviewing what I already know about the patient’s medical history. “So, Mr. Jones, it sounds to me like you have high blood pressure, high cholesterol and gout. Is that correct? What other medical conditions do you have?”

Be prepared for your initial assessment to be incorrect. Medications are often prescribed for multiple reasons. If the patient reports, “I don’t have gout.” follow up with a question about the medication that lead you to that assumption. “Why do you take Uloric?” The patient may only know that they take it for painful, swollen joints. Or you may learn about a new use for the medication in question.

After the patient is done with their full medical history, I often throw out one last question that can uncover hidden medical conditions. “Are there any other medical conditions that your doctor is concerned about?” Physicians will coach their patients about medical conditions that they are at risk for long before they make an official diagnosis. This question can give you great insight onto where the patient’s medical history is headed.

Last Oral Intake

I’ll admit it. For the first half of my medical career I almost completely ignored the patients last oral intake. With the exception of diabetics, I just didn’t see how the question could be useful to me. I was wrong.

I figured out that I was wrong when I finally started asking the question. Suddenly, I found a wealth of information about the patient’s appetite, social and daily activity, life stressors, questionable food intake and changes in diet regimen. The patient’s ability to eat, desire to eat and volume of food intake can give you great insight into what their life has been like in the 24 hours prior to the 911 call.

I also like to know what it was that the patient last ate and, if you can find a diplomatic way to ask, how much. When the patient tells me what they ate, I can often get a feel for how much they ate by asking, “Was it good?” What I really want to know is, how has their appetite been? I’d also like to know if they are newly dieting. I probe this by asking if they’ve had any recent changes in their dietary patterns.

If the patient’s symptoms are GI related I may tangent off into the quality of the food. Was any of their food intake in the last 24 hours sketchy? Was it prepared outside of the home? Did anyone else eat the same thing and, if so, are any of them feeling sick?

Events Leading Up To Present Illness or Injury

You may find that you end up covering some of the events leading up to patients 911 call when you ask about the patients symptoms. What the patient has been feeling tends to get twisted up with what the patient has been doing. If you diverge into OPQRST you will inevitably run up against the patients activities prior to their symptoms when you ask about provoking factors and symptom onset.

This is your opportunity to probe the patient’s recent activities a little further. Have they been active of static? Was there an emotional component to what was happening in the patients life at the time the symptoms began? Many of our patients’ are more prone to recognize symptoms when they are already upset about something else and some of our patient’s complaints can have a specific emotional component to them.

With trauma, we can get caught up in the details of the event itself and leave out one crucial detail, was there a medical symptom prior to the accident? When the patient describes a traumatic event, don’t forget to ask, “What made you (insert event here).” “Mr. Jones, What made you drive off the road?”, “Mrs. Sims, what made you fall down?”. When discussing the event, always consider a medical precipitating factor and adjust your questions accordingly.

When you’re versed in the different variations of the SAMPLE history and you stay focused on the global meaning behind the questions, you can feel free to let the questioning drift off on tangents. Take the questions to where they lead you. Return your patient back to the path when you’ve found all you can or strayed too far off topic. The SAMPLE technique is a well-worn trail, but it has lots side paths. Good subjective history takers are masters at exploring the side paths and always finding their way back to the main trail.

 

 

Comments

  1. Personally, I’m not a big fan of the SAMPLE history because I think it over simplifies the history and leaves too many things out. For example, where’s the social history? Are we teaching our EMTs to ask about alcohol, tobacco, and drug use? What about surgical history in addition to a medical history (in case the patient leaves out that they had an appendectomy 2 years ago because it’s no longer a current illness?)? Where’s the family history?

    Finally, where is the review of systems (ROS)? Being distinct from the HPI, the ROS is the safety net for the history. It’s going to catch both other complaints that the patient might have, as well as giving you a second crack at any associated symptoms that should have been a part of the HPI, but were missed.

    Obviously some of these sections takes longer than others, but if SAMPLE is going to be the baseline standard for history taking, it leaves quite a bit out.

  2. Steve Whitehead says:

    Joe, I’m glad your comment will be the first one readers see, because you are so right. And you make a point that I should have, perhaps, made more clearly in the post. The SAMPLE history is a foundational tool but it is a terribly incomplete tool. It’s a good starting point. It will lead you right to a bunch of really good questions. But, if you get the idea that it is a complete subjective assessment, you’re mistaken. There are a host of, what I would call “complaint specific questions” that still need to be addressed.

  3. phil grantham says:

    I like this article I a new EMT and I feel I have better understanding of “SAMPLE”

  4. Excellent post!!

    As a fairly new paramedic, I’m realizing these tools are so useful when reviewing your assessment techniques. I have to admit, one of the only assessment acronyms I actually think about during a call is OPQRST. By the time you pass your internship, History/Allergies/Meds/etc is so engrained that I don’t really forget to hit (most of) them. For the next question I ask, I go off of what makes most sense bases on C/C and patient presentation. I haven’t killed anyone yet. Haha!

    But this post points out how useful it is going back and reviewing the acronyms that we learn in school, and why they are the “gold standard.” If not useful in the moment during a call, they are certainly useful to remind us WHY we are asking these questions, and help us dive deeper into what the information might tell us (e.g. above ideas on last oral intake). They are “academic” acronyms vs. “practical/tactical” acronyms.

  5. Fantastic article. I’m currenly an under-grad student in Australia (3year degree in paramedics)…. SAMPLE is a foundational tool yet it stumps me. We arrive at a “scenario” and 6 questions are popped off – do you have allergies?; on medications? etc etc. and apparently our patient history is done. I agree that they are a foundational tool to set the scene, but very limited. each one can open a pandora’s box.

  6. Thanks for the article, it really made a lot of sense to me. I use sample all the time and it was nice see that some of my rabbit trails were not unusual!

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