Emergency medical responder (EMR)/Patient history

If the patient has an altered level of consciousness and cannot provide sufficient information, ask family members present, bystanders, or any other reliable means at your disposal.

First use the acronym S.A.M.P.L.E.

• Symptoms. Determine the patients chief complaint and any other obvious symptoms
• Allergies. Determine if the patient has any allergies.
• Medication. Determine if the patient has taken any drugs or has any prescriptions for drugs.
• Past, pertinent medical history. Determine if the patient has a history of similar injuries or illnesses, as well as if the patient has any chronic disorders (i.e. epilepsy, diabetes, COPD, asthma).
• Last oral intake. Determine what the patient has ingested over the past 24hrs
• Events leading up the injury or illness. Determine what the patient was doing when the injury or illness occurred.

Second use O.P.Q.R.R.R.S.T. to describe the pain or discomfort from the chief complaint.

• Onset. Determine what was happening when the pain or discomfort started.
• Provokes. Determine what makes the pain or discomfort more severe.
• Quality. Ask the patient to describe the pain or discomfort.
• Region. Determine where the pain or discomfort is located in the patients body.
• Radiates. Determine if the pain or discomfort radiates to any other part of the body.
• Relief. Determine if anything the patient does, has done, or is doing helps to reduce the pain or discomfort.
• Severity. Determine the severity of the pain or discomfort.
• Time. Determine when the pain or discomfort started.