Medical History Gathering 2021

EPC 1 – MEDICAL HISTORY GATHERING
GUIDELINES
 This is one possible way to approach hx gathering. It is not the only way. It is not the way that you “have to” do it.
It is a suggestion.
 The goal is to find out the full picture; be a medical detective.
 Starting with the reason that they called 911, then finding out what has been going on in recent days/weeks
leading up to today, then finding out what longer term medical issues they deal with. The chart below starts on
the right, then works backwards in time (to the left). Feel free to edit if you would prefer it to move left to right.
 SAMPLE and OPQRST items are included in here, except last meal, and allergies. Don’t forget these. :)
 As you start to learn hx gathering, it is a great idea to use a mnemonic such as SAMPLE and OPQRST. The structure
of a mnemonic will serve as your anchor to make sure you haven’t missed anything. Then explore and branch-off
of that mnemonic, as you seek to get relevant details. SAMPLE and OPQRST are the bare minimum. As a clinician,
you need to seek not just to check off the boxes of the bare minimum. You are seeking to figure out the full,
relevant, picture, which allows you to make accurate tx decisions, and allows the staff at the hospital to increase
the effectiveness of their pt care. Good hx gathering is “advocating for your pt”.
 Note: OPQRST can be applied to “pain” questioning, AND ALSO to many other topics of questioning, such as other
signs and symptoms.
 Be sure to use vocabulary that the pt can understand. Be careful with terms like Respiratory, Cardiac, TIA, etc….
 Ask one, clear, open ended question, and wait for the answer. Avoid stacking two or three questions into one
sentence.
3rd LONGER TERM MED HX 2nd RECENT BACKGROUND 1st CURRENT EVENT – START HERE
What diagnosed or long-term In connection to what is What happened today that made you
medical problems/conditions do you happening today, help me to call 911?
have? understand what lead up to it?
- What medical conditions do you have? - Have you ever experienced this - When did it start?
- How long have you had it / when were before? - What were you doing when it started?
you dx? - How long has this been happening? - Has it been non-stop / steady since it
- Do you take any prescribed meds? If so, - Have you experienced this started? Or has it come in gone/fluctuated?
what are they / what do you take them recently? - When it started what was it like, on a
for? - When was the last time this scale of 1-10? - Has it been that number the
- Any changes to your meds? (new, stops, happened? whole time or has it changed?
or dosage increase or decrease) - Explain, - When, - How often, - Did it come on gradually, or suddenly?
- Do you take your meds as you should? - Was it like this last time or is it - Where is it? Does it radiate to other parts
Or do you ever miss/forget to take them? different today? of your body?
- Has it been under control? Improving? - When ______ happens, what does - Can you describe it? Has it been that way
Worsening? it normally feel like? since it started or has it changed?
- When was the last incident __? - Does it typically go away on its - Is there anything you can do to change it?
- Describe that last incident – severity, own? Or do you do something that What? Show me
etc, did you go to the hospital? makes it go away? - Can you make it feel better? How?
- Are you currently receiving tx? - How long does it normally last? - Does anything make it feel worse?
- Do you have an upcoming check-up or - How does this effect your life /ADL? - Do you have any ideas about what might
appt. regarding these conditions? - Do you have homecare / PSW / OT be causing this?
- When did you last see a MD about this? support? If yes, how often, and what - Is it only _____________ that’s bothering
And what did they say about the do they help you with? If not, do you today? Do you have any other
condition at that time? you need it? complaints?

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EPC 1 – MEDICAL HISTORY GATHERING

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