Good mnemonic systems help us to avoid missing important patient assessment steps and questions. The SAMPLE interview mnemonic is a reasonably helpful mnemonic system for obtaining important patient information:
Signs/Symptoms reported by the patient.
Allergies
Medications
Past Medical History
Last Oral Intake
Events leading to this episode of injury or illness.
All of the above information is vital to assessing and treating any patient. But, obtaining a complete and accurate SAMPLE history requires very specific questioning techniques.
Unfortunately, no core curriculum texts (and very few instructors) adequately train Prehospital or Inhospital emergency medical personnel precisely how to Interview people! In fact, to my knowledge, the only medical personnel who are consistently trained to adequately interview someone are those who enter psychiatric medicine! Why do I know this? Because before I worked in EMS, I worked as a psychiatric-care-technician for a State psychiatric facility.
"GOLDEN RULE #1" OF INTERVIEWING PATIENTS:
Avoid "closed-ended-questions" when interviewing patients about anything!
A "closed-ended-question" is one that can be answered with a "yes" or a "no."
"Are you having difficulty breathing?" is a closed-ended-question.
"How's your breathing?" or
"How does your chest feel?"
are "open-ended-questions."
Open-ended-questions require the patient to actually describe his complaints. Thus, open-ended-questions yield much more accurate, much more patient-specific, information than closed-ended-questions.
Additionally, open-ended-questions yield this better information much faster than closed-ended-questions.
Remember those horribly long "health-history" surveys you've occasionally had to fill out - the ones with four columns of health problems and little "yes" / "no" check boxes for each problem? Asking closed-ended-question is just like verbally taking the patient though one of those surveys. Once you start, you have to specifically ask about each and every medical problem - asking a multitude of questions - to get your "yes" or "no" answer.
And, unless you carry a little complete-health-history-survey-form to read from, you'll forget to ask about some health problems. (Murphey's Law = the problems that you forget to ask about will be the problems that the patient has had! But, when using open-ended-questions, if you don't specifically ask about them, the patient will never tell you about them.)
Closed-ended-questions are crappy questions.
Crappy questions yield crappy information.
Crappy information contributes to misdiagnosis and inappropriate or delayed treatment.
"GOLDEN RULE #2" OF INTERVIEWING PATIENTS:
Use the patient's words, and only the patient's words, when referring to - or reporting - his complaints.
Once a patient offers you descriptive information, use only the patient's terminology when referring to his complaints, or when reporting his complaints to others. Never, ever, put your words in place of the patient's words.
If a patient says, "My chest feels really tight!" do not later refer to his complaint as chest "pain." He didn't complain of chest "pain." He complained of chest "tightness."
When you use words the patient didn't use to refer to his problem or describe it to others, you are sending the patient the message, "I'm not listening to you!" Patients do not respond well to providers who aren't listening to them - consciously or unconsciously.
Another danger of using your words to describe the patient's complaint - another danger of using open-ended-questions - you can "lead" the patient to complain of things that he isn't actually experiencing.
"Are you short of breath?" ... "Well, now that you mention it ... yeah!" vs.
"How's your breathing?" ... "My breathing's fine! It's this tightness that's bothering me!"
Leading the patient to complain about things he's not experiencing can lead to misdiagnosis and inappropriate or delayed treatment.
"Labeling" patients is a bad habit. But, in an effort to be faster, all care providers do it. I'm not going to fight that battle. But, whatever you do, never, ever "label" a patient using any term that the patient hasn't used! Not only can that lead the patient to complain of something he's not experiencing, it can misrepresent the patient's complaints. Misrepresenting the patient's complaints can lead to misdiagnosis and inappropriate or delayed treatment.
"GOLDEN RULE #3" OF INTERVIEWING PATIENTS:
Denial = Positive Confirmation.
If a patient denies complaints involving a specific area/function, require him to confirm that there is nothing wrong with that area/function.
"How's your breathing?"
"It's fine. I told you, it's my chest that hurts, dammit!"
"So, your breathing feels completely normal?"
You're absolutely right! That's a "close-ended-question. But, it's a quick way of getting the patient to either confirm his denial of a complaint, or to explain why he didn't mean to "deny" a complaint. Often, patients don't consider complaints other than their primary complaint as being "important" enough to tell you about. Or, they worry that they'll distract you from fixing their primary complaint if they "fuss" with telling you about other signs and symptoms.
Notice that, although I used a closed-ended-question, I didn't use one that suggested a complaint! (Such as "So, you're not short of breath?") Suggesting complaints leads patients to complain of something they're not experiencing. Whereas, suggesting the absence of complaint requires the patient to "argue" with you if they are experiencing a complaint. Then, you can require them to better describe their complaint.
"How's your breathing?"
"It's fine. I told you, it's my chest that hurts, dammit!"
"So, your breathing feels completely normal?"
"Well, no ... sometimes I get a little short of breath."
"When do you get a little short of breath?"
"Well, when my chest gets tighter."
"When does your chest get tighter?"
"When I have to do something ... you know ... like go up or down stairs
... or lift something. But, it's my chest that hurts, dammit!"
(Patients are a treat, aren't they?! Gotta luv 'em!)
SIGNS/SYMPTOMS REPORTED BY THE PATIENT =
"What's wrong?"
"S" PART ONE:
You quickly want to determine what complaints (signs/symptoms) this particular patient has, and what do the complaints feel like - using open-ended-questions.
"What's wrong?" ... "What's bothering you?"Plz notice that I do NOT suggest asking, "What made you call us today?" or "Why did you call us?" Those kinds of questions, even when "sweetly" intoned, are antagonistic.
"What's wrong?" ...
"What can I do for you today?" ...
"How can I help you today?"
If a patient says, "My chest hurts!" ask him, "How does it hurt?" or cue him to, "Describe what it feels like."
Avoid asking closed-ended-questions such as, "Is it squeezing pain?" ... "Is it stabbing pain?" Again, once you start asking closed-ended-questions, you'll have to pedantically offer a multitude of pain-quality-terms just to determine what the patient's chest feels like. And, if you never offer a term that the patient considers appropriate, you'll either never know what the patient's complaint feels like - OR, the patient will "settle" for one of your words (even though it's not quite "right") just to get you to shut up!
Get all the information you possibly can about the first complaint that the patient describes before you go on to any other complaint. If you don't, you'll get distracted, and gather only incomplete information.
If you ask, "What's wrong?" and the patient replies,
"Oh! My chest is tight, and my head aches, and I can't catch my breath!":
stay with the first complaint until you've got all the information you need about it. "Tell me about this chest tightness. When did it start bothering you?" Once you've got all the information about the chest tightness, then ask about the next complaint the patient listed. "Tell me about your head aching."
(Patients generally list their complaints in order of how much they're being bothered by them. And, that's a good thing. But, don't forget that a patient's "chief complaint" - the first-mentioned or most patient-concerning complaint - does not always represent their most primary emergency care requirement!)
"S" PART TWO:
"What else is bothering you?"
If you don't ask the patient to describe his other complaints, you may not learn about them at all. Patients are often so completely preoccupied with their primary complaint, that they're relatively unaware of other complaints. (This phenomenon is likely the genesis of the, "He didn't tell ME that!" aggravations frequently experienced after turning patients over to other care-providers.)
Even when the patient's primary complaint doesn't represent his most life-threatening problem, it's what's bothering him the most. So, he won't tell you about anything else until you've "fixed" what's bothering him the most! OR - until you firmly require him to tell you about his other complaints.
Require every patient to fully describe each complaint or altered-condition that he's experiencing - in his own words.
"What else is bothering you?"
Keep asking "What else?" ... "What else?" ... "What else?!" until the patient insists that he's described all of his complaints for you.
"RADIATING PAIN" or "RADIATING COMPLAINTS":
"Does your chest discomfort go anywhere?"
"No! It's right here!"
Guess what? Ask that same patient,
"What else is bothering you?"
"Well, my left shoulder and arm have been kind of achy the past day or so. But, its my chest that hurts, dammit!"
Patients should never, ever be expected to decide what is a "radiating" complaint and what is not! They don't understand the significance of "radiating" complaints - nor do they even recognize what a "radiating" complaint is!! They don't perceive their complaints as "going anywhere" but where they feel them. (And, "Does your chest discomfort go anywhere?" is a closed-ended question, anyway!)
Same problem with "associated" complaints:
"Do you have any complaints associated with your chest discomfort?"
"No! It's my chest that hurts, dammit!"
Medical providers are the only persons who should decide which of a patient's complaints are related to his other complaints, be they "radiating" complaints or "associated" complaints. But, medical providers cannot decide whether the patient has radiating or associated complaints until they've determined the entire list of the patient's complaints.
So, keep asking, "What else is bothering you?" ... "What else?" ... "What else?" And then, YOU decide what complaints the patient reports represent "radiating" or "associated" complaints!!!
"S" PART THREE: The Head-To-Toe Open-Ended-Question Survey
For every patient, especially a "reluctant describer," after you've asked, "What is bothering you today?" and, "What else is bothering you?" and, "What else?" ... "What else?" - do a quick verbal survey of their body, beginning with their head and working your way to their extremities.
(If you feel completely confident that you've heard everything you need to hear about a specific body area, you can skip it - or summarize the complaints you've noted in that area, asking them to confirm or deny your understanding of their previously-reported complaints.)
"How does your head feel?"
"How does your neck feel?"
"How does your chest feel?"
"How's your breathing?"
"How does your belly feel?"
"How does your back feel?"
And so on.
Remember Golden Rule #3: Whenever the patient denies complaints in an area, require him to confirm the denial:
"How does your belly feel?"
"Fine!"
"So, your belly feels absolutely normal?"
(Again, for denial-confirmation purposes, a closed-ended question works fine -
as long as you're suggesting the absence of a complaint!)
Whenever the patient identifies a "minor" complaint (or denies that an area feels "completely normal"), ask him to expand upon his complaint:
"So, what's not 'normal' about it?"
"Well, what do you mean by 'odd'?"
"Please describe what you mean by 'dizzy'?"
"What kind of 'achy problems'?"
And so on.
BREAK TIME!
I know that all this sounds incredibly lengthy and time-consuming. (We're on page SEVEN, fer gosh sakes!) But, it's only the explaining of these techniques that is so lengthy and time-consuming. Using these techniques will require a conscious effort and some practice. But, plz believe me - once you start using them, they'll save you an enormous amount of time, vastly improving your ability to obtain information, greatly improving your ability to provide the best possible emergency care. (Thus, using these techniques, your patients will respond better to treatment and more positively reflect upon your performance as a care-provider!)
END OF BREAK.
ALLERGIES:
Contrary to the vast majority of core curriculum text books and care-provider-courses, do NOT ask questions such as, "Are you allergic to any medications? ... Are you allergic to any foods? ... Other substances?" These are all closed-ended-questions. Using them requires a longer amount of time to obtain information, and substantially increases the likelihood that you'll miss vital allergy information. Thus, these are all crappy questions.
Instead, ask, "What are you allergic to?"
Then ask, "What else?" Then ask, "What else?" And keep on asking, "What else?" until your patient insists that he's told you of all his allergies.
MEDICATION QUESTIONS:
Learning about the medications your patient takes is vital. Medication information can provide important clues to the patient's past medical history, direct you to explore problems that might be "side effects" from medications (such as dehydration or electrolyte problems secondary to diuretic use), and assists your evaluation of the patient's current complaint.
But pay close attention to how you ask the patient about medications. Throughout medical history, experienced care providers have been asking "crappy" medication questions - ones that routinely yield incomplete information. Incomplete information leads to medical treatment errors. And, that's a "crappy" thing, isn't it?!
One of the most common crappy medication questions is, "Do you take medications prescribed by a doctor?" (Even the open-ended-question-version of that question is crappy: "What medications do you take that are prescribed by a doctor?") In response to such a question, patients are entirely unlikely to report the over-the-counter medications they take; such as daily aspirin ("I saw on TV that it would decrease my risk of heart attack, so I started taking it."), multiple non-prescription inhalers, or gallons of antacid. Medications that aren't prescribed by a doctor are just as important to a person's health and well-being, just as indicative of medical problems, and just as important to emergency medical care considerations.
Another frequently-asked crappy medication questions is, "What medications do you take every day?" (See? Open-ended, but still crappy.) The patient will probably tell you exactly that, and only that. If you ask that question, the patient likely will not tell you about taking an occasional nitroglycerin tablet, or getting immunosuppressant therapy everyother day, or being injected with antipsychotic medications every three or four weeks. Not all medications are taken "every day." Yet, all are just as important to medical history and emergency care considerations.
There are many other similarly "crappy" medication questions. Thankfully, I'm not going to waste print exposing them. Instead, I'll simply share with you a 4-question system for determining almost all the information you really need to know about any patient's medications.
Medication Question Number One: Ask the patient, "What medications do you take?" That's it! "What medications do you take?" Then, note what medications the patient reports.
Medication Question Number Two: Ask, "What other medications are you taking?" Especially when patients take several medications, they tend to stop reciting them long before the list is completed. Or they forget to mention one or four of them. If you stop your medication-questioning after the patient has listed two or three medications, and go on to another line of questioning, your patient is not going to correct you! You'll rarely (if ever) hear, "Oh! Excuse me, but I haven't finished telling you about all my medications!"
You must keep asking, "What other medications do you take?" ... "What else?" ... "What else?" until you're sure that you've obtained a complete list. ("That's it! I swear it! Those are all the medications I take!")
Medication Question Number Three: "What medications are you supposed to be taking, but aren't?"
Medications are expensive. When a prescription runs out, and the patient doesn't have the money to refill it - or doesn't want to spend his money getting a medication refill when it's needed - he may stop taking the medication.
Many people find the odor and taste of potassium extremely offensive. So, they keep taking their Lasix, but stop taking their potassium.
When traveling, a patient may decide to stop taking his diuretic because he doesn't want to have to stop traveling and pee every 15 minutes!
Or, after using the grocery store's machine to check his blood pressure for a couple weeks, and finding it identified as "normal" (both times), a patient may stop taking his antihypertensive medication. ("Well! My blood pressure's normal now!")
For whatever reason they do it, patients may stop taking medications when they shouldn't. And they rarely ever tell anyone about it. When a patient isn't taking all the medications he's supposed to be taking, you need to know about! Is his emergency related to not taking his medicine?
When they list their medications for you, patients may or may not include the medications they're supposed to be taking but aren't. So, no matter what medications they've listed, it's important for you to ask, "What medications are you supposed to be taking, but aren't?"
You may or may not get an honest answer to that question. (No matter what reason they've used to "justify" stopping their meds, underneath it all, patients know that they shouldn't stop taking them without being told to!) But, certainly, if the patient admits to not taking one drug he's supposed to be taking, remember to ask, "What other medications are you supposed to be taking, but aren't?"
And keep asking, "What else?" ... "What else?" ... until the patient insists that, "That's it! Those are the only medications I'm supposed to be taking, but aren't!"
Medication Question Number Four: "What medications are you taking in a way that is different from how you were told to take them?" Patients may be taking their medications, but if they're not taking them the way they're supposed to be, the medications won't effect them the way they're supposed to. This question identifies underdoses, overdoses, and otherwise-nontherapeutic uses.
Sometimes, in order to save money, patients take only half the prescribed dose of a medication. If the prescribed dose of a medication isn't alleviating their problem, they may take extra doses. Or (for whatever reason), they'll take them at times other than when they're supposed to. ("I take my nitroglycerin whenever I start to feel light-headed.") You need to know about such medication-taking alterations. (Especially since the patient's physician probably has no idea that the patient has altered his medication regimen.)
"What else?" ... "What else?"!!!
There are tons of other medication questions that patients could (and often should) be asked. Questions about Meds they've just started ... just stopped (under orders to do so or not) ... "vitamins" they take ... and so on. But, by learning to routinely use at least these Four Medication Questions, and learning the basic interview techniques identified in this program, medical care providers quickly realize how to create their own, "Magic Med Questions," based upon individual patients' needs!
PAST MEDICAL HISTORY:
According to core curriculum text books, the "P" of "SAMPLE" stands for "Pertinent" Past Medical History. But, who is to say what is "pertinent" and what is not? Certainly, you cannot expect the patient to decide what is "pertinent" and what is not! Additionally, core curriculum text books all suggest extremely poor methods of questioning patients regarding their Past Medical History.
Rather than wasting time going through a lengthy (and probably incomplete) set of common and crappy closed-ended-questions ("Have you been sick?" ... "Do you have diabetes?" ... "Do you have heart disease?" ...), simply ask the patient: "What medical problems have you had in the past and when did you have them?" ... "What else, when?" ... "What else, when?"
Also, ask "What physical injuries have you had in the past and when did you have them?" (Patients don't always understand the word, "trauma") ... "What else, when?" ... "What else, when?"
Then you can mentally note (later record) the patient's complete Past Medical History, and make your care-decisions accordingly.
LAST ORAL INTAKE:
"What was the last thing you drank or ate, and when did you drink or eat it?" ... "What else, when?" ... "What else, when?"
EVENTS LEADING TO THIS EPISODE OF INJURY OR ILLNESS:
"What kinds of things were going on, or what were you doing, before this happened?" ... "What else, when?" ... "What else, when?" ...
If you suspect that it's pertinent, "What happened that bothered you yesterday?" ... "The day before?" ... and so on.
SUMMARY:
"GOLDEN RULE #1" OF INTERVIEWING PATIENTS:
Avoid "closed-ended-questions" when interviewing patients about anything.
"GOLDEN RULE #2" OF INTERVIEWING PATIENTS:
Use the patient's words, and only the patient's words when referring to - or reporting - his complaints.
"GOLDEN RULE #3" OF INTERVIEWING PATIENTS:
Denial = Positive Confirmation. If a patient denies complaints involving a specific area/function, require him to confirm that there is nothing wrong with that area/function.
THE SAMPLE HISTORY SECRETS:
SIGNS/SYMPTOMS
The above document is the most "current" version of the handout that accompanies my SAMPLE Interview Secrets educational presentation.
Email Charly at: c-d-miller@neb.rr.com