Chief Complaint & History Gathering
History gathering is an important skill. Through appropriate questioning and investigation, crucial information may be gathered to assist in patient management. It is very important to be objective so as to avoid tunnel vision. Develop your own method of questioning that will assist in producing the information listed below:
Chief Complaint
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- Identify main presenting problem.
- Establish Mechanism of Injury in order to identify the potential Pattern of Injury.
- Examples include:
- Weapon type (blunt, stabbing)
- Blade size, type, length (serrated or non-serrated)
- Number and speed of vehicles involved; impact points
- Seatbelts present and/or worn
- Airbags present and/or worn
- Cabin intrusion
- Windshield / headstrike
- Gather information to determine treatment priorities and formulate plan for treatment, SAMPLE.
Assess complaints and signs and symptoms using OPQRST mnemonic:
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Onset Was onset of symptoms fast or slow?Pain When did the pain start? Was it sudden or gradual? What were you doing when the pain started?Quality What words would you use to describe your pain?Radiates Point to the area that hurts the most, where does it go from there?Severity Use the PAINLOG™ as the determination of severity of pain levels or if PAINLOG™ not available verbally ask pain level e.g. on a scale of 0 – 10, 0 being no pain and 10 the worst pain imaginable, what is your pain level.Treatment / Tablets What treatment (if any) are you receiving from your doctor/hospital? What tablets (if any) have you been prescribed? Are you taking any other tablets?
Obtain patients pertinent medical history using SAMPLE mnemonic:
Signs and Symptoms What can be seen? What is the patient complaining of?Allergies Do you have any allergies?Medications Are you taking any prescribed medication(s)?Pertinent History Do you have any i.e. cardiac problems / diabetes?Last oral intake What was the last time food or drink was consumed?Events leading up to… How and when did it occur? Has it occurred before?
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For Trauma gather information relating to the Mechanism of Injury.
Past Medical History
- May be chronic or acute
- Previous injuries
- Previous operations
- Obstetric/gynaecological considerations
Medications
- Attempt to note which medications the patient is taking.
- May need to be transported with patient for hospital to document.
Scene
- Additional useful information may be gathered from the scene such as evidence of drug use, domestic problems, mental functioning
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