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 or 15 lines
- Physical Examination - 950 characters or 15 lines
- Diagnosis - 100 characters for each diagnosis
- History Findings and Physical Examination Findings - 100 characters for each field
- Diagnostic Study/studies - 100 characters for each study recommendation
- Examinees may add rows to the History Findings, Physical Examination
Findings, and Diagnostic Study/Studies sections up to a maximum of
eight rows each.
A PDF version of the Patient Note Screen is 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 complete sentences and phrases. Note that only two studies are ordered under the Diagnostic Studies section; this is acceptable.
Patient Note Example Two is written in a list style. There are no complete sentences, although there are some complete phrases. Note that only two studies are ordered under the Diagnostic Studies section; this is acceptable.