What Is a SAMPLE History?

Mary McMahon

A SAMPLE history is a quick overview of a patient's pertinent medical history to assist care providers in the process of offering appropriate interventions. “SAMPLE” is a mnemonic to help care providers remember all the information they need to collect when taking a patient history. Paramedics, nurses, doctors, and other first points of contact in a medical emergency are all familiar with the process of quickly collecting relevant information to assist with patient care and make decisions in tense situations.

The medical history form is considered a private document.
The medical history form is considered a private document.

At the same time a care provider collects a SAMPLE history, she also usually takes vital signs and makes some general observations of the patient. In cases where history collection is not possible because a patient is unconscious or in an altered state, observation can provide very important clues into the patient's condition.

Paramedics are trained to quickly collect medical information and make decisions accordingly.
Paramedics are trained to quickly collect medical information and make decisions accordingly.

The “S” in SAMPLE history stands for signs and symptoms, including those reported by the patient as well as those the care provider may observe during the interview. A patient might report shortness of breath, for example, and the care provider could note that the patient has trouble speaking because of his breathing problems. Care providers also ask about allergies, including medication allergies that might complicate treatment.

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Next in the SAMPLE history are medications, any drugs a patient may be taking. These include over-the-counter preparations as well as prescriptions. It is helpful to provide information about any drugs a patient recently stopped taking, as these can linger in the system and cause complications. The “P” refers to past medical history, with a specific focus on similar problems. Asthma or allergies might be relevant if a patient is wheezing and coughing, for instance, while a broken leg 15 years ago might not be as pertinent.

The "L," or last oral intake, is also a piece of information the care provider wants to collect. This can be useful for checking for allergies. It may also become important if a patient needs emergency surgery, as recent consumption of food or drink could complicate general anesthesia. Finally, the care provider taking the SAMPLE history wants information about the event or events that brought the patient to seek treatment. Sometimes this may be evident; paramedics responding to a car crash do not need to ask why they are there. In other cases, the patient may need to provide some background information to help the care provider understand the primary complaint and the reason for seeking treatment.

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