How to do a better patient assessment?

As you do more, you will also learn what questions to ask based on what you see. You will have plenty of "That probably would have been good to ask" moments and tuck it away for the next time you come across it. It's a mix between OPQRST/SAMPLE and more specific questions to help you get a better idea of what you are looking at.
 
I really don't to OPQRST/SAMPLE questions any more unless I absolutely have to. FWIW, half the time I have no idea why my patient is in one of my rooms in the ER beyond "leg pain" or "cough." I just look at the census board, notice that I have a new patient and off I go to assess my new patient. I pretty much start each contact the same way. "Hi, I'm Akulahawk, and I'll be your nurse for today. What brings you in to the ER today?" I'll then let the patient talk about their problem. I'll ask some clarifying questions along the way and I'll usually ask about pain, nausea/vomiting, dizziness, shortness of breath, tingling or numbness, problems with peeing/pooping (GI or GU problems, just to check other systems that aren't related to the complaint. The meat of the questions really happen when I'm doing a more focused assessment on a particular system that is likely involved with a given complaint. The more you know about A&P and pathophys, the more specific you'll be able to ask questions about various problems. You should, if possible, hang around nearby when one of the providers does their evaluation because sometimes you'll notice questions that are good ones to ask...
 
I do not think SAMPLE and PRQST are helpful, generally, the individual components are helpful in certain situations (particularly PQRST for pain) but in general I think they are an extremely poor way to take a history.

Becoming good at history taking (and examination) is a learnt skill built on a foundation of knowledge of anatomy, physiology and pathology.

There is no practical way to boil it down to an acronym.
 
As many stated above you will learn what to ask from what you see. If you have any doubts do it as you learned in school. The list from top to bottom, its fail proof.
 
You must log in or register to reply here.
Back
Top