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Be patient about the 'Patient Note' (PN)


Whew!! You are done with what you dreaded the most - the SP (Standardized Patient) encounter ! You come out of the room relaxed and ready to write the PN - but lets bear in mind that quiet a few people have been failing on the patient note. We need to get professional and have a protocol for that one too !

First things first: To write or type the PN is the question - Personally, I handwrote the PN.

Two reasons for this :

a. Though I type really fast - I tend to type using the Instant Messenger lingo like "ur" instead of "Your", "2" instead of "to" and so on ...and with the tense atmosphere I was sure I will make those errors subconsciously
b. What if the computer shut down or something ? .Aaaaaaarrrrggggh !!! I know a few unfortunate guys whose scores were not reported due to technical errors on the USMLE Step1 and Step2 exams. Not heard that on the CS yet...but...what if...


General Rules for PN :


a. Practice , practice , practice writin' patiently within 9 minutes
b. Broken English is fine , like Google keywords ! Grammar can take a back seat
c. Have a protocol like the one mentioned below to manage time well !
d. Use only standard abbreviations permissible on the PN - Read more about this below
e. D/Ds don't have to be 5 in number ! You could write even 2 or 3 but its EXTREMELY IMPORTANT that you arrange them in the order of relevance / possibility to the SP that you saw !
f. Some people tend to mention therapy in the Management - NEVER do that , you are only supposed to write Investigations on the USMLE Step 2 CS Exam.


My Protocol for completing a PN on time :


1. D/D and Management first
2. Then Chief Complaints and their description
3. Significant Negative History
4. Systemic Examination

This ensures that the Higher grade-earning points are done within time.

5. In the time left, finish off PAM HUGS FOSS and General Examination (Always copy vitals from the door please - even if you got different readings !)

Sample Patient Note: If you would like to see two examples of handwritten Patient Notes - follow the PN sample link on the Left side-bar. The pages have been extracted from the old ECFMG CSA manual and gives two excellent samples - one using complete sentences and one using short broken english. Both are acceptable, though I recommend practing the short way to save time :-)

By the way, for your D/D needs - I highly recommend wrongdiagnosis.com ! - an excellent resource...

Q. My Handwriting Sucks and looks pathetic - will I lose Points ?
A. Well, as long as it is UNDERSTANDABLE - you are fine. If it is totally illegible and cannot be understood - either due to miserably bad handwriting or appalling spelling errors, you lose points. And this is what USMLE.org has to say:

"The patient note is considered a communication tool; poor legibility or spelling errors that interfere with the patient note reader's ability to comprehend the note may have a negative impact on your score. If your handwriting is difficult to read, you should probably type your patient note."

Basically practice writing some timed PNs and ask someone to read it - if his/her tempers shoot up due to irritation caused by inability to understand what you wrote, you need to either practice more or seriously reconsider typing ;-)


Q. Are we allowed to use Abbreviations on the PN ? Do you have a List of acceptable abbreviations for USMLE Step 2 CS?
A. OYOCYC ! Did you get that ? It was MY abbreviation for "Oh Yeah Of course You Can" - note how it puzzled you a bit. Now imagine trying to decipher thousands of wierd abbreviations ! The point is that you don't wanna bug the examiners with abbreviations that seem very commonplace to YOU. Let's either not use them at ALL, or keep them at minimum with Standard Abbreviations. Click Here to look at the list of Standard Abbreviations for the Patient Note as published by the 2007 USMLE Step 2 CS Manual.I hardly used any myself though !


Q. Do we mention about counseling on the PN - like DM , HT, etc. ?
A. No ! Counseling only inside the room with the SP :-) The Patient Note is only for D/Ds, Findings, History and Investigations - No Interventions !


Q. I wanna practice typing the Patient Note - is there a sample Patient Note Simulation online?

A. Sure ! Usmle.org site has exactly that - Click here





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COMMENTS ON ""

 

Anonymous Anonymous said ... (2:17 PM) : 

do we need to check the vitals at all ourselves or we can just leave it n copy the ones provided?

 

Blogger Digitaldoc, MD said ... (2:32 PM) : 

I did a Pulse exam for each case as part of Gen. Exam - but on ur PN , mention the vitals exactly as the ones provided.

 

Anonymous Anonymous said ... (1:01 AM) : 

Thanks digitaldoc for the precious info. I have a doubt about whether to type or write. Is it that if u write, u can write it small (font) and squeeze all the info in the little space provided?

 

Anonymous nooha said ... (5:32 PM) : 

Digidoc
your information about CIS & PN is so valuable thanks as these were the most "treaturous" for me in the exam
May God help you as much as U R helping others

 

Blogger Digitaldoc, MD said ... (6:38 PM) : 

I have now posted sample handwritten patient notes on this page - download them to get a good idea on how they are graded by the ECFMG ...

 

Anonymous Anonymous said ... (12:36 PM) : 

Hi digitaldoc,

The link for the PN sample has expired. Can you please put them again

Thanks

 

Blogger Digitaldoc, MD said ... (1:53 PM) : 

Sure ! Sorry for the inconvenience here...

 

Anonymous Anonymous said ... (7:21 PM) : 

hi, the link for PN samples has expired again. can you re-post it again please? thanks

 

Anonymous Anonymous said ... (10:05 PM) : 

Digidoc,the link to the sample PN has expired again.Can u pls renew.

 

Blogger karinns said ... (10:11 PM) : 

Digidoc,the link to the sample PN has expired again.Can u pls renew.

 

Blogger Digitaldoc, MD said ... (11:44 PM) : 

Done....I apologize for the inconvenience

 

Anonymous Anonymous said ... (8:50 PM) : 

i cant get to the handwritten pn , can u plz help

 

Anonymous Anonymous said ... (4:37 AM) : 

digitaldoc this file has expired, can you please put them again

 

Blogger Digitaldoc, MD said ... (6:44 PM) : 

Its up again ! [:)] Thanx for the reminder

 

Anonymous Anonymous said ... (9:46 AM) : 

Love this website, amazing content and guidance!!!!

I have a question about the note, is it true now that you can type the pt note instead of handwriting? There is supposed to be a computer station outside of the exam room right? Did they have this in Houston?

Thank you so much!!

 

Blogger Digitaldoc, MD said ... (11:39 AM) : 

Yes you can - for any case you can either type or write ! this applies to all centers. There will be a writing desk AND a computer station outside each room.

g/l and thanks for the kind comments !

 

Anonymous Anonymous said ... (11:34 PM) : 

For clarification; you can or cannot switch from computer to paper in the middle of the exam? Anybody?

 

Blogger Digitaldoc, MD said ... (1:35 AM) : 

You May - but once you start Typing for THAT case, you can't switch to a paper one..

 

Anonymous Anonymous said ... (8:59 AM) : 

Hi doc,

it seems the handwritten PN expired again (07/10/06). I know it's a lot of work to maintain this site, but could you please have it up and running again? Thanks.

 

Blogger Digitaldoc, MD said ... (11:25 AM) : 

My Apologies for my ineffeciencies...
Problem rectified...:-)

 

Anonymous Anonymous said ... (8:14 PM) : 

Hello,
Can we write technical terms on patient notes while describing history.
Thanks,

 

Blogger Digitaldoc, MD said ... (9:41 PM) : 

Except for the chief complaint - which must be in the patient's words, the rest can be medical lingo :-) that's a good point u have asked about ! Thx

 

Anonymous Anonymous said ... (2:33 PM) : 

hey digitaldoc i cant see anything at the righ side of the bar.can you please help me about that?

 

Blogger Digitaldoc, MD said ... (3:34 PM) : 

Good you brought that up - having the links on the right was causing problems to many - so I swapped the two bars ..so all USMLE step 2 Tips links will now be on the left instead :-)

 

Anonymous Anonymous said ... (1:26 PM) : 

thanks for your help digital doc. I was wondering if you know where i can get an empty patient note template, as I would like to start practise writing in it and see what changes need to be done to my hand writing. Thanks a bunch digital doc.

 

Anonymous Anonymous said ... (2:09 AM) : 

digitaldoc, u r an angel in disguise!! :)

is the size of the paper for the PN on the exam exactly the same as that in First Aid? if not, is there any way we can get an estimate of the size, to know how large to keep the handwriting?

also, where exactly in USMLE site is the list of abbreviations?? i got lost trying to find it!!!!
thanks a million in advance :)

 

Blogger Digitaldoc, MD said ... (2:47 AM) : 

Answer 1: I have now posted links to the patient note templates - in addition First Aid for Step 2 CS aslo carries Patient Note Template

Answer 2: Yes, I did find them roughly to be the same size. ABout the link to common abbreviations for the patient note - I am posting that on a separate post and shall be linking that on this article. Thanks :-)

 

Anonymous Anonymous said ... (1:26 AM) : 

My God!
What is D/Ds?????

 

Blogger Digitaldoc, MD said ... (3:45 AM) : 

Oh God ! D/D = Differential Diagnosis ;-)

 

Anonymous Anonymous said ... (4:08 PM) : 

Do we have to copy all the vitals dow in the PN or only postive vitals. In the Sample PN's released by USMLE they only mention the BP. Also do we need to give side headings like PMH,FH etc? Thanks

 

Blogger Digitaldoc, MD said ... (4:43 PM) : 

Yeah - write down at least the relevant vitals to your case - I would say write down wuts given.

No need for side-headings, but you can write PMH, FH, etc as neat separate concise paragraphs

 

Anonymous Anonymous said ... (9:57 AM) : 

Hi, Digitaldoc. I am confused about the order of diagnostic workup. USMLEWORLD recommends listing most specific first,in order of priority, but FA recommends listing most simple and straitforward first. Could you clarify this for me?

About the patient note size, the space in sample template of ECFMG seems much bigger than first aid. Do you think the size of sample template is magnified?

Thank you for your great site.

 

Blogger Digitaldoc, MD said ... (4:45 PM) : 

I don't think that really matters - all relevant ones must come in the picture.

Order may be more important when you list down the Differential Diagnosis and I would calibrate my order of Investigation list as per my D/D list

I would stick with the ECFMG template

 

Anonymous Anonymous said ... (5:54 PM) : 

Hello DIGITALDOC,
If I decide to type the patient note, do I need to check for the typing mistakes, punctuation markings,keeping CAPITAL LETTERS. Do all these thigs matter when they evaluate my PN. Even I wanted to ask whether I should write down all the vitals given in the PN or shud I write as WNL.
JAGAN

 

Blogger riz said ... (4:59 PM) : 

hi
i would like to ask abt the pt note cuz i failed dat .should we write short or narrative style?

 

Blogger Digitaldoc, MD said ... (12:59 PM) : 

To Jagan: Avoid Spelling mistakes, About punctuations etc. - their absence should not distort what you are trying to convey on the note. Yes, WNL should be fine for the Vitals, provided the ones provided are really WNL. But I would mention the values where they are espcecially relevant, like BP and pulse for a case of orthostatic hypotension, even if they are WNL

Answer 2: Short is fine too, saves time - I used that.

 

Anonymous Anonymous said ... (7:19 AM) : 

I failed step2CS due to PN though I suspect something deeper involved cause I typed n was satisfied. Dont know wat went wrong. Could you shed some light on the investigation part? Are we supposed to write "specific" investigations (like CThead for headache) FIRST or stick to old fashioned CBC, CUE, CXR, Xrayskull, FIRST

 

Blogger Digitaldoc, MD said ... (2:54 PM) : 

Order would be more important for the Differential Diagnosis. for orders, I would concentrate more on keeping all of them relevant and not missing out the special investigations for that particular set of Differential Diagnoses

 

Anonymous Anonymous said ... (3:51 PM) : 

Hi!
I must thank you so very much for such a great blog!. And I hate to bother with this for the 1456922 time, but the PN link is not working again. Thank you for your time and knowledge.

 

Blogger Digitaldoc, MD said ... (3:53 PM) : 

No prbs..i must thank you ! I have updated the online patient note practice link

 

Anonymous Anonymous said ... (10:08 PM) : 

hey digital doc,
2 questions pls
1)do we have to tell SP all the investigations?
2)what if i missed out certain investigation during the closure, can i still write them on the PN?
thanks a million

 

Blogger Digitaldoc, MD said ... (1:57 AM) : 

No - you dont have to tell them all, just 2-3 of the most relevant ones. "We will need to order a few tests like a Chest Xray to look at your lungs better, test your sputum for bacteria, some blood tests and a few others.."

Yes - do write them on the PN in decreasing order of relevance / importance

 

Anonymous Anonymous said ... (3:16 PM) : 

Is a mouse available at the computer stations? I really hate laptop touch-pads and if there's no mouse, it would really slow down my scrolling/typing.

Thanks!

 

Blogger Digitaldoc, MD said ... (3:26 PM) : 

:-)

Yeah you get a mouse !

 

Blogger Digitaldoc, MD said ... (3:30 PM) : 

The monitor sits on the writing desk, while the keyboard and the mouse sits on a sliding board below the desk as in this picture

 

Anonymous Anonymous said ... (12:44 AM) : 

what if the history i write extends into the physical exam section of the pt note..is that ok?

 

Blogger Digitaldoc, MD said ... (9:29 AM) : 

If you can clearly indicate that it is still history and not physical exam.

 

Anonymous Benji said ... (10:33 PM) : 

Though I guess it makes sense you handwrite to avoid using internet slang, don't worry about the computer shutting down -- the document saves itself real time (supposedly) in the chance that the machine dies. I have never heard of this happening. But I guess it's whatever you feel most comfortable doing. I preferred to type, too, because I could reorganize my thoughts without crossing out. Then again, I often ran out of space in typing and had to abbreviate or rephrase things...

 

Blogger Oz Paats said ... (11:26 AM) : 

Dr Digital doc.

in the Follow up section... What is written 1st? The most simple or the the one that gives you the diagnosis?
i.e: CT first in a neuro case or CBC?

 

Blogger Digitaldoc, MD said ... (11:18 AM) : 

The general rule is = More Diagnostically relevant one first - so in a case with an obvious Space occupying lesion possibility , yes I would list a CT first

 

Anonymous Anonymous said ... (7:21 PM) : 

Hi DD, you are really gr8.
if chose to 'type' PN, can we insert something, if forgot earlier??

 

Anonymous Anonymous said ... (11:34 AM) : 

Hi digidoc,

ur csprotocol is awesome. i am religiously going through the topics you have discussed and it definitely increases my confidence to face the patients in the exam. as i was going through this particular topic "BE PATIENT ABOUT PATIENT NOTE" i saw u mention that someone had their scores not reported because they faced technical errors in step1 or 2. well i gave my ck a few days back and at the end of the exam after i finished the survey i got a message saying "fatal error has occurred.. contents saved automatically but manual routing is required.. i immediately informed the proctor at prometric and she came and wrote down the message but said i have nothing to worry as it is saved but i wont be getting a printout of me having taken the exam.. but i checked twice and she said i will surely be getting my scores. i was not worried about that until i saw something similar to my experience being mentioned in this topic.. please let me know whether there will be a problem in my scores being reported...

 

Blogger Digitaldoc, MD said ... (2:36 PM) : 

If you have been assured by the proctor, they already know about the problem and it should be fixable and fine

 

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  • Besides other history taking specific to the chief complaints that the patient has, use this mnemonic to remember specific data collection points:
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