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  #1  
Old 12-27-2009
3abass's Avatar
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Idea! CS Opening Statements

Hi guys,
Let's share with each other what you think is the best opening statement with SP during the exam.

I have this:

Good morning/Good Afternoon Mr/Mrs/Ms ....
I am Dr. last name, am the physician on duty today.
Do you find everything in the room OK.
How may I help you.


Please share your versions so that we can come up with the best to start with the SP.

Thanks..
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  #2  
Old 12-27-2009
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Don't forget to say nice to meet you
Don't forget to smile
Don't forget to put the drape
Don't forget to ask him/her permission to write notes while taking the history

Otherwise, the opening statement you mentioned is OK
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  #3  
Old 12-27-2009
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Hello Mr Jones or Hello Ms Jones. why? because in the exam you get tired and may not remember if it is 1201 and accidentally say good morning. so I would prefer "hello" that works any time of the day.

Miss is fine, in the exams it does not indicate if the patient is married or single. however, in the exam Miss Jones would suffice.

Hello Miss Jones My name is Doctor Jennifer Reynolds I am the physician in the office today. why? because some patients are in the er, some in the clinic and some in your office (as per the exam) so if you say " I am the physician in the office today your covered, your the physician in the office that will suffice. Using the first and last name is highly recommeded, just in case there are 12 Dr. Reynolds in the hospital at least they will know you are Jennifer Reynolds.

Its nice to meet you. shake hands or not either way is OK. Are you comfortable in this room? if they say no they are not comfortable, ask is there anything I can do to help you. then...I am here to do a physical exam and ask you some questions is that ok? before I go on I want to mention if they are coughing offer water, if they look sad ask are you ok? and if they are in acute pain wait a moment before you begin to speak and then gently and slowly ask, can I get you something to help you feel better like a blanket., water, dim the lights in these cases the sp is asked not to answer any questions until you ask the correct question. If they ask for meds, say I need to do a physical exam and ask you some questions after that we will run some tests and I will be able to give you a medication for your condition I need to know what is going on first before we order meds, is that OK.

Then say... May I put this drape on your lap. It is better to stand and not sit, but if you need to sit ask do you mind If I sit down and write while we talk... or do you mind if I write while we talk.

Ok Ms Jones can you please tell me how can I help you today?
They tell you what's going on
Then say... I am so sorry to hear that, it must be very uncomfortable for you,. allow them a moment to respond .. like yes its been uncomfortable or thank you for your concern, then say, I will do everything I can to help you feel better.

Then continue to focus on the diagnosis and ask questions from there, if you are asking the correct questions they will give you answers if you are not asking the correct questions they will say no, or hm.. not at all.

Do not forget to ask family history, sometimes the SP is instructed to give you a long and complicated family history that is expected to be in the patient note. They will also say when you ask them to rate their pain on a scale that "oh I never rated my pain before"

good luck
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3abass (12-27-2009), Mahir (12-29-2009), Sabio (12-28-2009), StepTaker (12-27-2009)
  #4  
Old 12-27-2009
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thank you csevideo,
You really made everything clear for me
I'll sign up for your service soon
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