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Cathy: FYI: My Patient Notes--practice for CS
作者:USMedEdu
发表时间:2009-04-03
更新时间:2009-04-03
浏览:1136次
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发信人: dreamcatchin (Cathy), 信区: MedicalCareer
标 题: FYI. My Patient Notes
发信站: BBS 未名空间站 (Fri Apr 3 09:57:03 2009)

献丑, 希望能够抛砖引玉

I scanned several patient notes (4 in total) I wrote when practicing CS and
wanted to share with you. There were written within 5 days of my exam and
written in a timed fashion. i.e. they were finished in 10 minutes after I
did a practice case in 15 minutes with my friend.

These, by no means, are good examples but I wanted to use them to
demonstrate several points I was trying to come across about patient notes.

1. Write everything in the box provided on this sheet of paper;
2. Legible!!! This was why I wrote every word with upper case letters;
3. Use bullet points rather than full sentences;
4. Start from D/D and work up, then finish history and PE;
5. Use only the abbreviations provided by USMLE. During your exam, you
will be provided with the abbreviations. So if you can not memorize all of
them, it should not be a problem.

Sample Patient Note from USMLE--

http://www.usmle.org/Orientation/2008/PatientNote/pnmain.htm

希望大家都能一次考过, 以后MATCH进自己喜欢的医院和专业

Cathy
--


...自拔于流俗,而困而知,而勉而行,历百千艰阻而不挫屈;不求近效,铢积寸累,受之以虚,将之以勤,植之以刚,贞之以恒,帅之以诚,勇猛精进,坚苦卓绝...

※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 130.91.]

Attached:

http://www.usmle.org/Orientation/2008/PatientNote/pnmain.htm

Patient Note Information
Immediately after each patient encounter in Step 2 CS, you will be asked to handwrite or type (on a computer) a patient note similar to the medical record you would compose after seeing a patient in a clinic, office, or emergency department.


--------------------------------------------------------------------------------

Patient Note Interactive Simulation

Click here to access a practice patient note program, similar to the one you will use if you choose to type your note.

--------------------------------------------------------------------------------

Sample Patient Note
Various styles of writing patient notes for the Step 2 CS examination are acceptable. Two examples of handwritten patient notes can be viewed in portable document format (PDF) by accessing the links below; these demonstrate some of the acceptable variations in style. These examples are not meant to represent ideal or perfect patient notes, nor should they be assumed to be complete or accurate with respect to content. Both formats and styles, however, would be considered acceptable.

Patient Note Example One is written primarily in a narrative style. The History section is written in complete or nearly complete sentences, and the Physical Examination section also has fairly complete phrases. Note that only four studies are ordered under the Diagnostic Workup section; this is acceptable.

This note uses some abbreviations not included in the list of common abbreviations that is posted at each writing station, but they are common enough to be recognizable by the practicing physicians who rate the notes. The note is written in cursive script, but it is legible.


Patient Note Example Two is written in a telegraphic or “bullet” style. There are no complete sentences, although there are some complete phrases. In some parts of the History section, in particular, one or two words stand alone. The writer of this note has chosen to transcribe the patient's blood pressure from the examinee instruction sheet. You may wish to include vital signs if they are particularly relevant to the case.

In this note only four items are listed in both the Differential Diagnosis and in the Diagnostic Workup sections; again, this is acceptable. This sample also contains some abbreviations or symbols not included in the list of common abbreviations posted at each writing station, but, as in Example One, they are generally recognizable. This note is printed throughout, although a mixture of cursive script and printing is also acceptable, provided both are legible.



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