Writing the Step 2 CS patient note (medical record):

• Once you are sure that you have finished your patient encounter, exit the room and proceed to your desk.
• Start writing your patient note (medical record) on the Step 2 CS formatted paper provided.
• Take time to record the patient’s history legibly.
• Don’t write too much. Try to economize on the words and stick to conveying medical information. Write less, but convey more information.
• USMLE has begun giving Step 2 CS examinees, a choice to enter the patient note on a computer. This will take care of the legibility problem if you have a bad handwriting. You can also save space and write more.
• However, if you don’t know how to type fast, this may be a disadvantage.
• In any case, you can give the computer a try for your first patient. If you don’t like it, you can switch to writing by hand.
• When writing the patient’s history and physical examination, you must include both, relevant positive findings and important negative findings.
• Write a brief list of medical differential diagnosis, in order of priority. Start with the most likely. Aim to write at least five.
• You must also write relevant medical investigations that will help you in making the final diagnosis.
• If you are not sure what investigations to order, look at your list of differential diagnosis and order investigations to “rule in” or “rule out” the list.
• You are not required to write treatment plan or medication orders.