Patient Note Case Instructions

Class of 2009

Time:  25 minutes total per case

• 15 minutes with the SP, which includes reading the presenting situation.  A 5-minute warning knock will be given.

• 10 minutes for the Patient Note (PN) in the computer lab.  A two minute warning will be given. 

• Any time you do not use during the SP encounter can be used on the Patient Note, so you should go directly from the exam room to the Computer room to complete your PN (there is no break in time).

SP Encounter:

• Do not to ask to do genital, rectal, or breast exams during the SP encounter.  If you believe any of these exams should be done, include them in the PN under Diagnostic Work-up.

• During the USMLE 2-CS, a copy of the presenting situation is in the exam room so you will be able to take the presenting situation into the exam room with you during these cases, too.

Patient Notes:  You may handwrite or type your PN.

• The form for handwriting the PN will be on the proctor table.  Space will be cleared by some of the computers for this.  Write in your ID# and the case name on your PN form.  You are to use black (preferred) or blue pen for the note.  No pencils.

• The computer PN form will be on the computer desktop.  Select your name and the case name from the drop-down menus.  (Your ID# rather than your name will print on your PN for anonymous grading.)  Tab to the first field and begin typing.  There is a counter at the bottom of each field that tracks how many characters you have left.  You may tab from field to field.

• There are space limitations for both the handwritten and the computerized Patient Note.  For the former, you are to keep your writing inside the boxes.  For the latter, there is a counter at the bottom of each field that gives the number of characters remaining.

Completing the PN Sections:

• The PN has 4 sections:  History, Physical Exam, Differential Diagnosis and Diagnostic Work-up.

• You may complete them in whatever order works best for you.  However, if you complete the sections in the order they are listed on the form, make sure to leave sufficient time to complete the Differential Diagnosis and Diagnostic Work-up sections.

• Notes about Diagnostic Work-ups:

  • Diagnostic Work-up should NOT include drug treatment, therapeutic procedures, consultations, referrals or dispositions. 

  • Remember to include genital, rectal or breast exams if you would have done them.

  • You may enter more than one item on a line (eg, you can include all basic blood tests together).

  • f you don’t think any diagnostic tests are needed, say no tests needed rather than leaving Diagnostic Work-up blank.

Final Logistics:

• When time is up, the proctor will say Stop writing; Hit the Submit Button.  The Submit Button is located at the bottom of the computer PN form.  Handwritten PN forms should be given to the proctor.  All case notes should be placed in the recycle box as you exit the room. 

• You have several minutes to relax before your next patient, but when ready, go to your next scheduled exam room. 

Scoring:

• PNs will be rated globally based on the following criteria:  organization, quality of information, interpretation of data, absence of egregious/dangerous actions and legibility.

• PN Ratings are 1-9:  Unsatisfactory (1-3), Satisfactory (4-6), and Very Good (7-9).