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Patient Assessment

SAMPLE History: Getting the Full Story

A structured approach to collecting useful patient history.

September 18, 2024

What SAMPLE Stands For

SAMPLE stands for signs and symptoms, allergies, medications, past pertinent medical history, last oral intake, and events leading up to the incident. It gives a structured picture that helps guide treatment and informs the receiving facility.

Asking Good Questions

Use open-ended questions first, and follow up with specific ones. Ask about medication names, doses, and any recent changes. When the patient cannot speak, rely on family, bystanders, medical alert jewelry, or medication lists.

Why It Matters

Allergies can prevent dangerous reactions, and medication lists reveal conditions the patient may not mention. Last oral intake matters for patients who may need surgery or have diabetes. Always document the information clearly and communicate it during handoff.

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