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回答:考CS时如何写病历

(2007-04-03 18:56:32) 下一个

Question: " I failed CS though, because I could never finish writting patient note :(
Did you type or hand-write?"

So sorry to hear that. You can make it next time.

Never type, always hand write because the keyboards are all very crappy in test centers. It will be half slow comparing to hand writing.  I typed the first case then I realized this problem and changed to hand writing for all other cases. The reviewing physicians will be able to recognize any reasonable handwriting.

This is my suggestion for note writing:
1. Not necessary write the patient note in the given order. 
Fill the diagnosis first. three is enough.  Fill the treatment second. three is enough too.
Just fill though, do not waste time thinking too much. If you could not think good plans in 10 seconds, put CBC, CXR, Basic Chem Panel, then move on to other sections.
2. The next one to work on is HPI part. Put down words without much thinking too. Just recording what the patient told you is good enough. If could not remember the drug name they mentioned, just put generic name. For example, use NSAIDS instead of ibuprofen, if you do not know how to spell it.
3. Lastly put down the PE/System review part. Use abbreviations wherever possible.

Remember, you will get the most points JUST with all sections FILLED. The quality of note is much less important.

Hope that is useful to all Chinese USMLer.

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USMLE2 回复 悄悄话 Hi, any suggestions for step 2CK preparation? Looking forward to read your new post:DD
USMLE2 回复 悄悄话 Thank you so... much for sharing your experience! I really appreciate it :)

Aladdin's 回复 悄悄话 Very good points I have to say!
You must be very organized in real life!!
Good luck with your residency!!!
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