Steps for Focused History...(Step 1; including the definition of OPQRST)
1. Elicit history of C/C or problem (OPQRST):
Onset- sudden or gradual?
Provoking Factor- "What were you doing?"
Quality- "What does the pain feel like?"
Region- "Where does it hurt?"
Radiation- "Does the pain go anywhere else?"
Reoccurrence- "Has this happened before?"
Severity- "How bad is the pain?"
Time- "When did it start?"
Step 2 for focused history
2. Elicit personal History (HAM or SAMPLE)
H- medical history/under a physicians care
A- allergies
M- medications
OR
S- signs and symptoms
A- Allergens
M- medications
P- pertinent history
L- last meal
E- Events leading to the injury or illness
Step 3 and 4 of focused history
3. Perform a focused medical assessment
- based on the patient's complaint
4. Vital Signs
- blood pressure
- pulse
- respirations
- pupils
Step 5 and 6 of focused history
5- Special Questions
- ask questions specific to patients chief complain
6- Detailed physical exam
- complete head to toe examination
- must be conducted systemically starting at the head
- reassess vital signs
- continue emergency medical care
Step 7 of focused history
7- Ongoing assessment
- repeat initial assessment (ABC's)
- reassess and record vital signs
- repeat the focused assessment for other complaints
- check interventions
- note trends in patient condition
