A well-structured and professional USMLE Step 2 CS patient note template is crucial for effectively communicating patient information and demonstrating clinical reasoning skills. This document serves as a foundation for your clinical encounters and can significantly impact your overall performance on the exam.
Key Components of a Professional Patient Note Template
Patient Identifier: Clearly state the patient’s assigned number or code.
Date of Encounter: Record the date of the clinical encounter.
Time of Encounter: Note the specific time of the encounter.
2. Chief Complaint (CC):
Patient’s Words: Directly quote the patient’s primary concern in their own words.
Example: “I’ve been having chest pain for the past two days.”
Step CS Blue Sheet Shortness of Breath – Ecuadoctors
Image Source: ecuadoctors.com
3. History of Present Illness (HPI):
Chronology: Present the symptoms in a chronological order, starting from the onset.
Characteristics: Describe the quality, severity, location, duration, and associated symptoms of the chief complaint.
Aggravating and Alleviating Factors: Identify factors that worsen or improve the symptoms.
Timing: Specify the frequency and pattern of symptoms (e.g., constant, intermittent, nocturnal).
Impact on Function: Assess how the symptoms affect the patient’s daily activities.
Example: “The patient, a 55-year-old male, presents with a 2-day history of sharp, substernal chest pain that radiates to his left arm. The pain is worse with exertion and relieved by rest. He reports associated shortness of breath and diaphoresis.”
