USMLE is mandatory for the physicians of the USA. Without the USMLE license, no doctor can practice here. It’s a very tough as well as a challenging course. Physicians like you who have passed the USMLE Step 1 and Step 2 CK often ask for the tricks to writing USMLE Step 2 CS patient note properly.
Here we are with some guidelines that would be of help in this regard. Let’s check them out!
#1. Taking History: 15 minutes are allotted to take the patient’s history. You need to be very cool and patient to approach because if you miss something, you won’t get a second chance. Take your time to write down the possible diagnoses.
During the doctor-patient interaction, try to be specific to diagnose so that you don’t miss anything. We would recommend you not to write a broad history, just try to be precise. Focus on the chief complaint.
#2. Associated Symptoms: You should note down the associated symptoms along with the main symptoms like if the patient has vomiting tendency, nausea, diarrhea, cough or pain in the body. Also, encountering an upset patient is very common.
In these cases, you should be very positive about the things that are bothering them. Feel free to ask them about it. Assist the patients to make decisions in certain cases.
#3. Physical Examination: The first thing you need to do is to wash your hands before any physical examination. Now ask the patient for permission. Ask him if he is ready to get exposed for diagnosis. Check the problem areas only as you do not have the entire day for it.
When you find any positive physical signs, note that in your notepad. When checking a female patient, you can simply ask her to loosen her bra, don’t tell her to remove it completely. Be gentle to press any body part that hurts and take it into consideration. Examine a patient on direct bare skin for better understanding.
#4. Writing Notes: 10 minutes are allotted to take down notes. If you take more time, write it down on the notepad. The notes should be in narrative format. Only the personally obtained information should be written. Try to avoid unclear medical terms that are not familiar with everyone.
Note down the relevant history in brief instead of writing N/A. Write down the additional information like if any other family member of the patient has got the same problem or not to understand the disease clearly. You should write the exact medical terminology to describe a disease.
Note down 2 to 3 possible diagnosis. In the end, list the diagnostic tests that you recommend the patient and make it clear to him why the test is important.
#5. Communication with the Patient: Doctor-Patient communication is very important to know the exact history of the disease. You should achieve it by listening to the patients, expressing your sympathy, showing interest to their problems and by the effective skills you have gained to be a doctor.
Try to get engaged with your patients so that they don’t feel hesitated to tell you their problems. Ask them to feel free to let you know what they are going through.