Step 2 CS Patient Note Information
Immediately after each patient encounter in Step 2 CS, you will be asked to 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.
Patient Note Practice Program
Access a patient note practice program, similar to the one you will use when you type your note:
The character limits for each field on the patient note screen are:
Practice Note- History - 950 characters
- Physical Examination - 500 characters
- Differential Diagnosis - 80 characters for each diagnosis
- Diagnostic Workup - 80 characters for each workup recommendation
The patient note screen that appears during the actual examination will contain a status bar for each field, indicating how much space remains. A PDF version of the Patient Note Screen is also available
Sample Patient Note Styles
Various styles of writing patient notes for the Step 2 CS examination are acceptable. Two examples of typed 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.
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.
