USMLE Step2 CS PATIENT NOTE OVERVIEW

by Integrity USMLE (Posted Fri May 20, 2016 8:15 pm)Once you complete any encounter, you’ll be given at least 10 mins to compose a PN.I will start by saying for practice purposes try as much to be completing your PN in 8-9 mins( may be challenging initially but keep practicing).You need to strategize how to flow, navigate and complete this task. After you exit the patient’s (SP’s) room, try to take a few seconds to review the information you gathered, prepare your mind.Be confident that you can compose the best note; trust yourself (very important).Decide on the PN style you will use: ‘’narrative ‘’or ‘’Bullet’’ style. Chief complaint: CC, onset, freq, it’s progression, main presenting symptoms (a lot of mnemonics everywhere choose what works for you: ‘LIQORAAA’ for location, intensity, quality, onset, radiation, aggravating factors, alleviating/relieving factors, associated symptoms).Now that you’ve explored this case, then R/O differential diagnosis ( Neg. for : blah blah blah, or No: blah, blah , blah, or Denies blah, blah , blah)Document other key points: PAMHUGSFOSS:Previous episode, PMH/PSH, Allergy, Meds, Hospitalization, Urinary habits, GI habits, Sleep, FH, OBGYN, Sex, SOCIAL: Smoking, ETOH, Illicit drugs, occupation, diet , exercise, relationship status(married, single) , living condition etc..​PHYSICAL EXAM: key physical findings, includes pertinent positives and negativesPt. is in or no acute distressVS: WNLHEENT: NC/AT, EOMI, PE...
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