The USMLE Step 2 Clinical Skills (CS) exam assesses a medical student’s ability to gather information from patients, perform physical examinations, and communicate their findings to colleagues. One important aspect of this exam is the patient note, which is a written summary of the encounter that the student must complete within ten minutes after the encounter. In this article, we will discuss the USMLE Step 2 CS patient note template and provide some tips for effectively completing this task.
Table of Contents
- Patient Note Template
- Tips for Completing the Patient Note
- Reviewing and Revising the Patient Note
- Example Patient Note
Patient Note Template
The USMLE Step 2 CS patient note template consists of three main sections: the chief complaint, the history of present illness (HPI), and the physical examination findings. Each section has specific subheadings that guide the student in documenting the relevant information. Here is a breakdown of the template:
Chief Complaint
In this section, the student should briefly summarize the patient’s main concern or reason for seeking medical attention. It should be concise and specific, using the patient’s own words if possible.
History of Present Illness (HPI)
This section provides a detailed account of the patient’s symptoms, including the onset, duration, location, quality, aggravating or relieving factors, associated symptoms, and any previous treatment. The HPI should be presented in a chronological order and should include relevant positive and negative findings.
Physical Examination Findings
In this section, the student should document the relevant physical examination findings, including vital signs, general appearance, and any abnormal findings in each system. It should be organized and presented in a systematic manner, following the sequence of a typical physical examination.
Tips for Completing the Patient Note
Completing the patient note within the given time frame can be challenging, but with practice and preparation, it can be done effectively. Here are some tips to help you:
1. Use abbreviations and shortcuts
To save time, use abbreviations and shortcuts when documenting the patient’s history and physical examination findings. However, ensure that you use standard medical abbreviations that are commonly understood.
2. Be concise and focused
Avoid unnecessary details and focus on the key information. Use bullet points or short phrases instead of long sentences to convey the findings. This will help you save time and make your note more readable.
3. Practice time management
During your preparation, practice completing the patient note within the allocated time frame. Use a stopwatch or timer to simulate the exam conditions and improve your speed and efficiency.
4. Prioritize important findings
If you encounter time constraints, prioritize documenting the most important findings that are relevant to the patient’s chief complaint. This will ensure that you capture the essential information even if you are unable to complete the entire note.
Reviewing and Revising the Patient Note
After completing the patient note, it is crucial to review and revise it before submitting. Take a few minutes to read through the note, checking for any errors or omissions. Ensure that the note is well-organized, coherent, and accurately reflects the encounter with the patient.
Example Patient Note
Here is an example of a completed patient note using the USMLE Step 2 CS patient note template:
Chief Complaint:
The patient presents with a one-week history of cough and shortness of breath.
History of Present Illness (HPI):
The patient reports that the cough started one week ago and is associated with yellowish sputum. It is worse at night and with exertion. He denies any chest pain, fever, or chills. No previous treatment has been tried.
Physical Examination Findings:
Vital signs: Blood pressure 120/80 mmHg, heart rate 80 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F. The patient appears well-nourished and in no acute distress. Lung examination reveals decreased breath sounds and crackles in the right lower lobe.
In conclusion, the USMLE Step 2 CS patient note template provides a structured approach for documenting the encounter with a patient. By familiarizing yourself with the template and practicing time management, you can effectively complete the patient note within the given time frame. Remember to review and revise the note before submitting to ensure accuracy and clarity.