OPQRST: The Pain and Chief Complaint Assessment Mnemonic

OPQRST is the mnemonic EMTs and paramedics use to work through a chief complaint, most often pain. It stands for Onset, Provocation, Quality, Region and radiation, Severity, and Time. It is the history of the present illness in six questions, and done well it can narrow down what is wrong as much as anything else in your assessment.

What OPQRST is for

A patient tells you they have chest pain. That sentence fits a dozen diagnoses, some of them lethal and most of them not. OPQRST is how you narrow it. Each letter asks about a different property of the complaint, and the pattern of answers is what points you toward cardiac, respiratory, musculoskeletal or abdominal causes. You are not diagnosing on scene, but you are deciding how worried to be, what to look at next and what the receiving facility needs to hear.

It is also a structure for your report. A handoff that says the pain started suddenly at rest, is pressure-like, sits mid-sternal and radiates to the left arm, is an 8 out of 10, and has been constant for forty minutes has told the receiving clinician most of what they want to know in one sentence.

The six letters

O: Onset

Onset asks when the complaint began and how. Sudden or gradual matters: pain that arrives at full intensity in a second suggests a different process than pain that builds over hours. Ask what the patient was doing when it started, because exertion, rest, eating and sleep each point in different directions.

• "What were you doing when this started?"
• "Did it come on all at once, or build up?"
• "Have you ever had this before? Is it the same as last time?"

P: Provocation and palliation

Provocation asks what makes the complaint worse; palliation asks what makes it better. Pain that worsens with a deep breath, with movement or with pressing on the area behaves differently from pain that does not change at all. Ask what the patient has already tried, including anything they took before you arrived, and whether it helped.

• "Does anything make it worse? Breathing in, moving, pressing on it?"
• "Does anything make it better? Sitting up, lying still?"
• "Have you taken anything for it today?"

Q: Quality

Quality is what the complaint feels like, and the rule is to let the patient choose the word. Sharp, dull, crushing, tearing, burning and cramping are all useful and they are only useful if they are the patient's. If a patient struggles, offer several options at once rather than one: "Is it sharp, dull, pressure, burning, or something else?"

R: Region and radiation

Region is where it is; radiation is whether it travels. Ask the patient to point with one finger. Pain they can cover with a fingertip and pain they describe with a whole hand are different findings. Then ask whether it goes anywhere else: the arm, the jaw, the back, the shoulder, the groin.

S: Severity

Severity is usually a 0 to 10 scale, where 0 is no pain and 10 is the worst the patient can imagine. The number is the patient's report and not a measurement, so you record what they say rather than what you think it should be. Its real value is as a trend: ask again after every intervention and every few minutes on a long transport. For a child who cannot use numbers but can point to a face, a faces scale does the same job. For a patient who cannot self-report at all, an observational scale such as FLACC is used instead. Your service names which scales it uses.

T: Time

Time asks how long the complaint has lasted and how it has behaved since it began. Constant, coming and going, getting worse, getting better. Some texts fold the onset time in here as well; the point is the same either way. A clear time of onset matters for some conditions far more than others, and your protocol will tell you which.

OPQRST beyond pain

The mnemonic was built around pain and works for most complaints. Shortness of breath has an onset, things that make it worse and better, a quality the patient can describe, and a severity and a time course. So do dizziness, weakness, nausea and palpitations. Some letters will matter less for some complaints, and that is fine; skipping a letter because it does not apply is different from skipping it because you forgot.

How OPQRST fits with SAMPLE

OPQRST describes the complaint. SAMPLE describes the patient: signs and symptoms, allergies, medications, past pertinent history, last oral intake and the events leading up to the call. Most assessments use both, and the S in SAMPLE is usually where OPQRST happens. They overlap in places, most often when you ask about medications taken for the pain, and that is not a problem as long as you record the answer once.

In practice you do not need to finish one before starting the other. A conversation that follows the patient will move between them, and a good partner or a good form will make sure nothing gets dropped.

Common mistakes

• Reading it like a checklist. Six rapid questions in a flat voice gets six short answers. Ask, then listen to the whole answer before moving on.
• Leading the patient. "Is it crushing?" plants the word. "What does it feel like?" does not.
• Recording your number instead of theirs. A patient who reports 10 out of 10 while talking calmly is still reporting 10 out of 10. Document what they said and what you observed, separately.
• Asking severity once. The scale is most useful as a trend, and a single number cannot show you one.
• Missing radiation. Patients often do not mention it unless asked directly.
• Stopping at the first answer to onset. "This morning" is a start; what they were doing at the time is often the more useful half.

Practicing it

The mnemonic is easy to memorize and hard to use smoothly with a real person, because real patients answer the question you did not ask and skip the one you did. The way to get better is repetition with someone playing a patient who does not cooperate perfectly: a partner, a classmate or a simulated call. Practice handing the answers over in one or two sentences as well, because a history nobody can repeat back is a history that did not get used.

Practice putting your OPQRST findings into a structured handoff

The short version

• Onset, Provocation and palliation, Quality, Region and radiation, Severity, Time.
• Ask open questions and let the patient choose the words.
• The 0 to 10 number is the patient's report. Record it as said and repeat it to show a trend.
• It works for shortness of breath, dizziness and most other complaints, not only pain.
• OPQRST describes the complaint; SAMPLE describes the patient. Use both.
• Primary assessment first. History second.