Writing the Step 2 CS patient note (medical record)
Once you are sure that you have finished your patient encounter, exit the room and proceed to your desk.
Start writing your patient note (medical record) on the Step 2 CS formatted paper provided.
Take time to record the patient’s history legibly.
Don’t write too much. Try to economize on the words and stick to conveying medical information. Write less, but convey more information.
USMLE has begun giving Step 2 CS examinees, a choice to enter the patient note on a computer. This will take care of the legibility problem if you have a bad handwriting. You can also save space and write more.
However, if you don’t know how to type fast, this may be a disadvantage.
In any case, you can give the computer a try for your first patient. If you don’t like it, you can switch to writing by hand.
When writing the patient’s history and physical examination, you must include both, relevant positive findings and important negative findings.
Write a brief list of medical differential diagnosis, in order of priority. Start with the most likely. Aim to write at least five.
You must also write relevant medical investigations that will help you in making the final diagnosis.
If you are not sure what investigations to order, look at your list of differential diagnosis and order investigations to “rule in†or “rule out†the list.
You are not required to write treatment plan or medication orders.
Related Tags : clinical skills, step 2, patient
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