Immediately after each patient encounter in Step 2 CS, you will be asked
to handwrite or type (on a computer) a patient note similar to the medical
record you would compose after seeing a patient in a clinic, office, or
emergency department.
Click here to access a practice patient note program,
similar to the one you will use if you choose to type your note.
Sample Patient Note Styles
Various styles of writing patient notes for the Step 2 CS examination
are acceptable. Two examples of handwritten patient notes can be viewed in
portable document format (PDF) by accessing the links below; 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 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 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.
