Guerrilla Clinic Basics, OPQRST

We talked about the basics of the SOAP note, and what it was for. But how do you write one? What questions should you ask and in what order should you ask them? Without a standard way of asking questions, a history taking can quickly look like an episode of House with different people having ENTIRELY different ways of trying to figure out what is wrong.

In comes the OPQRST algorithm. This algorithm provides us with a standard and logical way of asking questions that is also easy to remember.

OPQRST stands for

O-Onset, when exactly did this issue arise, if it has been happening for a while, what made today the day to get seen for the issue?

P-Provocation or palliation, what makes the issue better or worse? This includes if the issue gets better with rest.

Q-Quality, describe the pain. This can be with guided questions. We want to know if the pain is sharp, dull, aching, throbbing, etc.

R-Region and Radiation. Where the pain is and where it may be radiating to.

S-Severity, this is the ever-wonderful 0-10 scale for pain. 0 being no pain, and 10 being the worst pain they’ve ever experienced or imagined. We are not just concerned with the current pain. It would be really helpful to know past pain, pain at rest, and (if applicable) pain when doing what aggravates the injury.

T-Time. When the injury or issue occurred. This lets us know if the injury or illness is a new development or if it has been ongoing for a period of time. If it has been happening for a while, what made them decide today was the day it needed to be addressed.

This is a rough guideline to follow when taking a patient history and is there to help you but does not need to be followed %100. If you want to learn how to take histories, write SOAP notes, practice presenting a patient to a provider, and a whole lot more, come on out to the Guerilla Clinic Foundation June 24-25. This will be quite the class and I have now opened it up to non-patrons. Sign up now before class seats fill up. We are going to cover a lot of the clinical side of things with this class. Expect more info shortly on this course.