General History Taking

Mastering the Art of Taking Patient History: A Guide for Paramedics

As a paramedic, your ability to obtain a comprehensive and accurate patient history is vital in providing efficient and effective pre-hospital care. Patient history serves as the foundation of clinical decision-making, allowing you to quickly assess the patient’s condition, identify potential life-threatening issues, and provide appropriate interventions. In this blog, we will explore the essential steps and techniques for taking a patient history as a paramedic.

History Taking

1. Approach with Empathy and Calmness

When encountering a patient, approach them with empathy and a calm demeanor. Patients may be frightened, anxious, or in distress, and your reassuring presence can make a significant difference in gaining their trust. Introduce yourself, explain your role as a paramedic, and assure them that you are there to help.

2. Gather Identifying Information

Start by collecting basic identifying information from the patient or any available bystanders. Obtain the patient’s name, age, and any known medical conditions or allergies. If possible, ask for their medical history, as this can provide valuable insights into their current health status.

3. Chief Complaint and Onset of Symptoms

Next, focus on the patient’s chief complaint—the primary reason they called for emergency assistance. Allow the patient to express their concerns fully, actively listening to their narrative. Pay attention to when the symptoms began, how they developed, and whether there were any triggering events. This information can guide your initial assessment and further questioning.

4. SAMPLE History (Signs/Symptoms, Allergies, Medications, Past Medical History, Last Oral Intake, Events Leading to Present Condition)

The SAMPLE history is a structured approach frequently used by paramedics to obtain critical information quickly. It involves inquiring about the patient’s signs and symptoms, allergies, medications, past medical history, last oral intake, and events leading to the current condition. Each element of the SAMPLE history helps you build a comprehensive picture of the patient’s health.

5. OPQRST Assessment (Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Time)

The OPQRST assessment is another valuable tool in gathering information about a patient’s symptoms. It allows you to explore specific aspects of their pain or discomfort. Ask about the onset of symptoms, factors that worsen or alleviate the pain, its quality (e.g., sharp, dull, burning), location and any radiation, the severity of the symptoms, and how the symptoms have changed over time.

6. Medical Conditions and Relevant Medical History

Probe further into the patient’s medical conditions and relevant medical history. Ask about any pre-existing illnesses, previous surgeries, or hospitalizations. Understanding their medical background can help you identify potential risk factors, drug interactions, and underlying health issues that may affect treatment decisions.

7. Medications and Allergies

Inquire about the patient’s current medications, including prescription drugs, over-the-counter medications, and herbal supplements. Additionally, ask about any known allergies or adverse reactions to medications or other substances. This information is crucial for ensuring the patient’s safety during treatment.

8. Events Leading to the Emergency

Determine the events leading up to the emergency situation. If applicable, ask about any accidents, traumas, or sudden changes in the patient’s health that prompted the emergency call. This information can assist you in identifying potential injuries or conditions that may require immediate attention.

9. Lifestyle Factors and Social History

While attending to the patient, gather insights into their lifestyle and social history. Ask about their occupation, living situation, and any recent changes in their daily routine. Inquiring about tobacco, alcohol, or substance use is also essential for assessing potential risks and tailoring treatment plans.