Appendix C

Sample Patient Note Styles

Various styles of writing patient notes for the Step 2 CS examination are acceptable. Two examples of handwritten patient notes are shown on the following pages; these demonstrate some of the acceptable variations in style. These examples are not meant to represent ideal or perfect patient notes, nor should they be assumed to be complete or accurate with respect to content. Both formats and styles, however, would be considered acceptable.

Patient Note Example One

Patient Note Example One is written primarily in a narrative style. The History section is written in complete or nearly complete sentences, and the Physical Examination section also has fairly complete phrases. Note that only four studies are ordered under the Diagnostic Workup section; this is acceptable.

This note uses some abbreviations not included in the list of common abbreviations that is posted at each writing station, but they are common enough to be recognizable by the practicing physicians who rate the notes. The note is written in cursive script, but it is legible.

Patient Note Example Two

Patient Note Example Two is written in a telegraphic or "bullet" style. There are no complete sentences, although there are some complete phrases. In some parts of the History section, in particular, one or two words stand alone. The writer of this note has chosen to transcribe the patient's blood pressure from the examinee instruction sheet. You may wish to include vital signs if they are particularly relevant to the case.

In this note only four items are listed in both the Differential Diagnosis and in the Diagnostic Workup sections; again, this is acceptable. This sample also contains some abbreviations or symbols not included in the list of common abbreviations posted at each writing station, but, as in Example One, they are generally recognizable. This note is printed throughout, although a mixture of cursive script and printing is also acceptable, provided both are legible.