#secondaryassessment

[readyems]

SAMPLE HISTORY

A very important part of your secondary assessment of a patient is getting what they call a SAMPLE history. It’s a helpful mnemonic that allows you to gather useful background information about the patient after you’ve assessed the History of Present Illness/Injury.

Signs and Symptoms (This is usually part of the assessment of History of Present Illness/Injury, so some use the mnemonic AMPLE instead)

Allergies (Food, medications, environmental)

Medications (Current or supposed to take, prescription, over the counter, recreational, birth control, medical IDs, herbal supplements)

Past Medical History (Medical problems, feeling ill, recent surgery or injury, seeing a doctor, doctor’s name)

Last Oral Intake (Food and drink can cause symptoms or aggravate, also important if PT needs surgery)

Events Leading Up (To current illness or injury)

This is all valuable information for your assessment of the patient, for your verbal report to the hospital, your hand off report to the hospital staff, and your chart.