S.A.M.P.L.E.
Signs & Symptoms, Allergies, Medications, Pertinent Past History, Last Oral Intake, Events Leading to Incident.
Signs & Symptoms
Obtain history of present illness i.e OPQRST
O.P.Q.R.S.T.
Onset, Provoked, Quality, Radiates, Region, Recurrence, Relief, Severity, Time, Interventions
Onset
Did this occur gradually or suddenly?
Provoked
What were you doing before this happened?
Quality
What type of pain is it?
Region
Where is the pain?
Radiates
Is the pain spreading anywhere?
Recurrence
Does the pain come and go or does it stay constant?
Relief
Does anything you do make it feel better?
Severity
On a scale of 0-10, 10 being the most painful, how bad does it hurt?
Time
How long has it hurt?
Intervention
Do you do anything to make the pain go away? i.e Inhalers, Nitroglycerin, etc.
PRBELLSS
Pulse, Respirations, Blood Pressure, Eyes, LOC (level of consciousness), Lungs, Skin, Sugars
AVPU
Alert, Verbal, Pain, Unconscious/unresponsive
Alert
Does the patient know where he is, what year it is, what his name is, and in a trauma scenario, do they know what lead up to it. Alert x1,x2,x3 and x4(trauma)
Verbal
Does the patient respond when you call out their name or any other verbal stimuli?
Pain
Does the patient respond to painful stimuli?
Unconscious/Unresponsive
The patient is out.
Baseline
First set of vital signs i.e pulse, respirations, blood pressure, skin.
DCAP-BTLS
Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, Swelling.
PERL
Pupils are Equal Reactive to Light
BRIM
Breathing (patent airway), Response (voice, pain, none), Eyes (spontaneous opening), Motor (movement of limbs)
5 Right for Medications
Right drug, Right patient, Right dose, Right time/date, Right route.