Advice for note taking in OSCE

[guitarguy23]

We have our first true structured OSCE next week where we will be given a case (chest pain, fatigue..etc) and have to perform the appropriate H&P.

Does anyone have a good way to jot down all that info you get from the patient while you are in there? I don't want to get everything jumbled or forget to write anything down, but I also don't want to be scribbling and looking down the whole time I visit the patient. Should I just shorthand a lot of it or is there a better way?

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[HatWobble]

It's not rocket surgery.

Write down history elements as you hear them-- nobody cares if you write things down during the history. Just make enough eye contact and you won't seem aloof.

For the PE, I imagine you're doing this on a standardized patient, so the vast majority of your findings will be normal. Just jot down whatever was abnormal (if anything) after you finish the physical. You won't forget anything, don't worry.

 

[Kaputt]

Use a pen or a pencil, and apply it to a page of paper. Apply it in such a way that you create letters to form words.

Should be fairly straight-forward.

 

[HLxDrummer]

I just did this last week. I just take brief notes for the Hx:
chest pain
1 hr
sudden
pressure
thinks MI
etc

Then for physical I try to only write down abnormal things or measurements such as liver span/BP/etc.

Also if you need to stop for a minute to get caught up or think, just let them know. They don't seem to mind. Much better to do this then rush and miss something.

 

[Sephiroth]

Do they actually check what you wrote down for your OSCEs? For us they don't and it's all about the presentation, so I only write down the bare minimum to make sure I don't forget things I need to repeat back, but most of it I can remember. That would have to change, though, if we needed to start entering in notes after the encounter in the future.

 

[colbgw02]

As some of you have already discovered, the real question being asked here is, "how do I write in shorthand?"

 

[HatWobble]

As some of you have already discovered, the real question being asked here is, "how do I write in shorthand?"

I think the better question is, "why does this thread exist?"