During this phase of the patient assessment, the mnemonic OPQRST and SAMPLE will be used to gather information about the chief complaint and history of the present illness. Baseline vital signs and a focused physical exam or a rapid medical assessment will be performed.

“SAMPLE” is a first aid mnemonic acronym used for a person's medical assessment. ... The questions that are asked to the patient include Signs & Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to present injury (SAMPLE).

SAMPLE is often useful as a mnemonic for remembering key elements of the patient's health history. S: Symptoms. A: Allergy. M: Medications. P: Past Medical History. L: Last Oral Intake. E: Events leading up to the illness or injury.

WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation.

Assessment & Plan Write an effective problem statement. Write out a detailed list of problems. From history, physical exam, vitals, labs, radiology, any studies or procedures done, microbiology write out a list of problems or impressions. Combine problems.

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

O: Onset of the event. P: Provocation/palliation. Q: Quality. R: Region/radiation. S: Severity.