USMLE Step 2 CS Patient Note
On the USMLE Step 2 CS exam, you will perform a series of 12 patient encounters, each consisting of 15 minutes with the patient and about 10 minutes to type a patient note. Here you will find a step-by-step guide for how to go through your patient encounters and a few tips for your patient notes.
15 Minutes with a Patient
Before the patient encounter starts, you’ll be outside the door. Have your clipboard and pen ready, but do not slide open the panel to reveal the doorway information or write anything down until you hear the announcement “Examinees, you may begin your first patient encounter.”
Now slide open the panel to reveal the doorway information. Take note of the patient’s name, age, vitals, his or her chief complaint, and the most important differentials. Knock on the door and enter the room (even if you don’t hear a response to your knock), then introduce yourself. Note any “unusual” items found in the room, such as something the patient is holding, that may be relevant to their case. Drape the patient if needed.
Take the patient’s history by asking questions, starting with the current problem and work back toward past medical history. Only ask relevant questions here, and keep the most likely differential diagnoses in mind as you do – as this is a timed scenario, you will not have enough time for a complete history.
Ask the patient for permission to begin a physical examination. Always remember to wash your hands with soap and water or hand sanitizer, or use gloves! Begin your FOCUSED examination with the most pertinent system, and make sure to observe the patient carefully. Talk to the patient and describe what you’re about to do as you continue the examination.
Make sure to never examine through the patient’s gown, examine sensitive areas, or repeat painful exam maneuvers. The patient is simulating pain for a reason!
At the 10 minute mark, there will be an announcement, at which point the physical exam should be about halfway done.
Now is the time for you to communicate to the patient the relevant points about disease prevention and/or health promotion (for example, smoking cessation), respond to his or her questions, and communicate your findings, the diagnostic steps you’d take, and why you’d take those steps. Make sure to speak in layman’s terms – you’re speaking with a “patient” who doesn’t have the same level of medical training as you do!
Wrap up your patient encounter, thank the patient, say goodbye, and leave the room. There is an announcement here as well: “This patient encounter is now over. You must leave the room.”
Writing the patient note
If you do finish your patient encounter in less than 15 minutes, the extra time is added on to the 10 minutes you have allotted to type your patient note. You will be notified when you have two minutes remaining to complete the patient note. You likely won’t have time to write down everything you’ve just learned, so make sure to write the most important information first.
The sections of the patient note are as follows:
History: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient’s problem(s).
The patient’s history can be presented either in narrative form or in list format for full credit.
Physical Examination: Describe positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of the examination you performed in this encounter.
Briefly describe your physical examination of the patient. Adding higher level details when applicable can result in a higher score.
Data Interpretation: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.).
Make sure to write the diagnoses in order of likelihood. Pull appropriate information from the history and physical examination sections above to support your diagnosis. Always write only one diagnosis per line and include supporting information, as not doing so will result in a lower score. Use medical terminology here. List the diagnostic studies you would order next, but leave out treatment, consultations, and referrals.
Just like in real clinical settings, you may not always be talking directly to the person who needs medical attention. While most of the standardized patient encounters found on the USMLE Step 2 CS exam will typically include a live patient and a physical exam, you may also find yourself facing a telephone encounter, speaking with a caregiver, required to demonstrate certain skills using a mannequin, explaining imaging on a tablet, or an entirely different communication scenario. For all of these special scenarios, instructions will be provided with the doorway information.