Patient History and Symptom Assessment (OPQRST)

Patient History and Symptom Assessment (OPQRST)

1. Two Tools, Two Jobs

You're going to use two history tools on every medical patient, and they do different jobs. SAMPLE gets you the patient's background — allergies, medications, past history. OPQRST dissects the complaint in front of you right now. This lesson is OPQRST.

The Guidelines call history-taking the primary component of the overall assessment of the medical patient. For most medical calls, what the patient tells you narrows the field. It narrows it further than anything your hands will find on exam. So the questions matter as much as the answers. Ask them in a way that leads the patient, and you've contaminated your own data.

One warning before you start asking anything. The chief complaint may be misleading. It can be verbal or non-verbal. And it's not always the most dangerous thing happening to this patient. So you're not just recording what they tell you first. You're working the whole picture.

Where the history comes from depends on whether the patient can talk to you.

• Responsive patient: you get it directly, focused on the chief complaint, and the scene corroborates — pill containers, medical jewelry, family, bystanders
• Unresponsive patient: you get it entirely from those same sources, plus medical devices on or around the patient