6 Tips to Help You Write Effective Notes During Standardized Patient Encounters

Writing patient’s notes is an essential part of passing the USMLE Step 2 CS. You must include notes that effectively educate the physician reviewing them with accurate information about standardized patient encounters.

The reviewing physician has no idea what you and the patient discussed in the exam room. It’s up to you to relay the information using notes within 10 minutes, before moving on to the next standardized patient (SP).

Use these six tips to help you learn to create brilliant patient notes during standardized patient encounters and after you become a practicing physician:

1. Utilize Extra Time

You’re allowed 15 minutes for each patient encounter. If you finish one early, use the extra time to work on that encounter’s patient note.

2. Be 100% Honest

Do NOT make up anything related to patient history or your exam finding. Only include the information you gathered personally when engaging with the SP.

3. Write Descriptively

When writing patient notes, be very descriptive when entering history, negative and positive, and physical exam findings. Remember, patient notes are essential to quality care, diagnosis and treatment.

4. Use Correct Medical Terminology

Never use slang in patient notes. Instead, use only exact medical terminology in your differential diagnoses.

5. The Goal is 3 Diagnosis

During USMLE Step 2 CS standardized patient encounters, your differential is critical to your clinical reasoning grade. Try to provide multiple possible diagnosis in your patient note differential. Aim for three to maximize your score potential.

USMLE Step 2 CS: SP Differential Rules to Follow

Here are some rules to follow for your differential while writing patient notes during the Step CS exam:

• Use your gathered information to ONLY list the MOST LIKELY diagnoses >>> List them in likelihood order, with the most likely being first and the least being last
• Include supporting element found during the physical exam or through patient history to support your diagnosis (manage your time wisely by using copy/paste whenever possible).
• Points may be lost if you don’t list the MOST LIKELY diagnoses, don’t provide supporting evidence and/or don’t correctly list them in the order of likelihood.
• You patient note must end with your list of recommended diagnostic tests.
• Do not leave the diagnostic studies section blank. If none are necessary, simply add “No studies indicated.”

Step 2 CS: Prepare Yourself for Writing Patients Notes in Under 10 Minutes

You only have 10 minutes to complete each SP’s notes during the USMLE Step 2 CS exam. To get a good score, you must know exactly what to type and how to write it up in a very short period of time.

MedSmarter Atlanta teaches medical students how to manage such critical tasks in a comprehensive CS review course. Learn how to write USMLE Step 2 CS patient notes from licensed physicians. Let us help you get a high score on your US medical licensing exam.

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