SAMPLE And OPQRST Assessment Order (What Each Letter Catches And When To Use Which)

SAMPLE and OPQRST are two of the most tested mnemonics in EMS education, and they cause more confusion than almost any other piece of the assessment. Students mix the letters, run them in the wrong order, or apply OPQRST to a trauma patient where it does not belong. The NREMT cognitive exam exploits the confusion. The practical stations expect both done cleanly. The fix is understanding what each framework actually does and when to use which.

SAMPLE is the history. It captures the patient's overall medical context. Allergies, medications, past medical problems. It is the background.

OPQRST is the chief complaint workup. It captures the story of why this patient called today. The pain, the symptom, the event that triggered the call. It is the foreground.

You do both on most patients. You start with SAMPLE on a medical patient because the history shapes the differential. You drill into OPQRST on the symptom that brought you there. This post breaks each one down letter by letter, shows where they fit in the assessment sequence, and points out where students lose points.

SAMPLE stands for Signs and symptoms, Allergies, Medications, Past pertinent medical history, Last oral intake, Events leading up to the illness or injury. It is the history-gathering framework used after the primary assessment and during or after the focused exam.

Signs and symptoms. Signs are what you observe. Symptoms are what the patient reports. Difficulty breathing reported by the patient is a symptom. Visible accessory muscle use is a sign. The S in SAMPLE captures both. Document the chief complaint here. "Chest pressure for 30 minutes, 8 out of 10, radiating to the left arm, with associated nausea and diaphoresis."

Allergies. Drug allergies first, then environmental allergies if relevant. Document the reaction. A reported penicillin allergy that produces hives is different from one that produces anaphylaxis. Some patients confuse side effects with allergies, the patient who says they are allergic to morphine because it makes them nauseated is reporting a side effect, not an allergy. Document what they tell you and let the receiving facility sort the rest.

Medications. All current prescriptions, over-the-counter medications taken regularly, supplements, and recent dose changes. The medication list is one of the highest-yield pieces of information you collect. A patient on warfarin who fell has bleeding risk. A patient on a beta-blocker who is in shock may not mount the expected tachycardia. A patient on an SSRI who is altered may have serotonin syndrome on the differential. Ask about compliance, when was the last dose, has anything changed recently.

Past pertinent medical history. The conditions relevant to the current complaint, plus any history significant enough to matter regardless. Cardiac history, respiratory history, diabetes, cancer, recent surgeries, recent hospitalizations. Look for medic alert jewelry on an unresponsive patient. Look at the pill bottles. Look at home medical equipment, an oxygen concentrator, a CPAP, a glucometer, a nebulizer.

Last oral intake. When did the patient last eat or drink, and what was it. This matters for surgical patients, diabetic patients, and patients who may need procedural sedation. A patient who ate a large meal an hour ago and is now coding has aspiration risk. A diabetic patient who has not eaten all day with hypoglycemia has a different trajectory than one who just ate.

Events leading up. What was the patient doing when symptoms started. Sudden onset during exertion, gradual onset over hours, an associated mechanism like a fall, a witnessed event, a recent illness. The E often produces the most diagnostic information of any letter in the mnemonic. A patient who became confused after a witnessed seizure is a different problem than a patient who became confused with no preceding event.

OPQRST stands for Onset, Provocation or Palliation, Quality, Region or Radiation, Severity, Time. It is the chief complaint workup, used after SAMPLE to drill into the specific symptom that brought you to the patient. OPQRST is most useful with pain and discomfort but the framework adapts to any chief complaint, dyspnea, palpitations, dizziness, nausea.

Onset. When did this start. Sudden or gradual. What was the patient doing at the time. Sudden onset of chest pain at rest has a different differential than chest pain that came on gradually during exertion. Sudden onset of severe headache is a red flag for subarachnoid hemorrhage. Onset captures both the time and the activity at the time.

Provocation and palliation. What makes it worse. What makes it better. Movement, position, deep breathing, palpation, eating. Cardiac chest pain classically does not change with palpation or position. Pleuritic chest pain worsens with deep breathing. Musculoskeletal chest pain often changes with movement. Pain that improves with rest and worsens with exertion is a classic angina pattern. Pain that improves with nitroglycerin suggests vasodilator-responsive etiology, often but not exclusively cardiac.

Quality. How does it feel. Sharp, dull, pressure, squeezing, burning, tearing, crampy. Use the patient's own words and avoid leading. Do not say "is it crushing?" because most patients will agree. Ask "can you describe what it feels like" and let them choose the word. Tearing chest or back pain is a red flag for aortic dissection. Pressure or squeezing is the classic cardiac description. Burning can be cardiac or gastrointestinal.

Region and radiation. Where is it. Where does it go. Cardiac chest pain classically radiates to the left arm, jaw, neck, or back. A patient who points with one finger to a precise spot on the chest is less likely to have cardiac pain than the patient who places a flat hand over the sternum. Renal pain often radiates from flank to groin. Gallbladder pain can radiate to the right shoulder.

Severity. On a scale of zero to ten, with zero as no pain and ten as the worst imaginable. Severity is the patient's report, not your judgment. A patient who reports a 4 with hemodynamic instability is still hemodynamically unstable, you treat the patient, not the number. Severity is useful primarily for trending after intervention. Re-ask after analgesia, after positioning, after intervention.

Time. How long has it been going on. Has it been constant or intermittent. Has it changed since it started. The patient with intermittent crushing chest pain for two days has a different urgency than the patient with constant crushing chest pain for 30 minutes, even though both meet criteria for cardiac workup. Time often shapes destination and transport priority more than any other letter.

The most common student mistake is treating SAMPLE and OPQRST as interchangeable. They are not. They answer different questions and they fit different parts of the call.

Medical patient with a chief complaint. Both. After the primary assessment, you gather SAMPLE for medical history context, then drill into the chief complaint with OPQRST. On a chest pain call you might gather SAMPLE first to learn the patient is a 62-year-old diabetic on metformin and lisinopril with prior MI, then OPQRST to characterize the current pain. SAMPLE builds the differential, OPQRST sharpens it.

Trauma patient with significant mechanism. SAMPLE only, often abbreviated. You are running a rapid trauma survey and limited time. SAMPLE captures medications, allergies, and recent oral intake. OPQRST does not add much when the chief complaint is "I fell" or "I was hit by a car." You can ask about pain location and severity during the focused exam, but the formal OPQRST is lower yield in significant-MOI trauma.

Trauma patient with isolated injury and clear chief complaint. Both. A patient with an isolated ankle injury who reports significant pain benefits from OPQRST on the pain and SAMPLE on the broader context. Allergies and medications still matter, especially anticoagulants in any patient who fell.

Altered or unresponsive patient. SAMPLE from bystanders, family, medic alert jewelry, and the environment. OPQRST is not feasible if the patient cannot describe their symptoms. Bystanders can sometimes give you Onset and Events, which are the highest-yield letters for an altered patient.

Four common errors account for most of the SAMPLE and OPQRST mistakes on practical exams.

Running OPQRST before SAMPLE. The skill sheet expects history before chief complaint workup on most medical assessments. Reverse it and you sound disorganized. Run SAMPLE first, then OPQRST, then focused exam.

Forgetting to ask Last oral intake. Students rush through the L because it feels like a low-yield letter on a non-trauma call. It is graded. Ask it.

Asking leading questions on OPQRST Quality. "Is it crushing?" is a leading question. The patient will say yes. The examiner notes it. Ask "can you describe what it feels like" and accept the patient's word.

Not re-assessing Severity after intervention. The S in OPQRST is your trending number. After nitroglycerin for chest pain, after oxygen for respiratory distress, after position change for back pain, ask the severity again. The reassessment closes the loop and is often a graded item.

The way to fix all four is verbal reps, ideally with someone calling the scenario at random. The brain that runs SAMPLE and OPQRST in your head silently is not the same brain that has to run them in front of an examiner with a clipboard or in a kitchen at 0300 with the family standing six feet away. You have to train the second one. The StruckBox NREMT EMT prep library drills SAMPLE and OPQRST through scenario-based cases that mirror the practical station structure, with explanations that point out where each letter belongs and where students typically skip. Pair that with practical-lab reps and the assessment sequence becomes automatic. The history flows, the chief complaint flows, and the examiner has nothing to deduct.