Documentation

[sdrs]

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If lab and diagnostic test results like X-ray and ECG are given with patient door info, do I need to read and document test results in patient note? I will be taking CS exam soon and I am just to make sure.

Thanks

 

[Golding]

If lab and diagnostic test results like X-ray and ECG are given with patient door info, do I need to read and document test results in patient note? I will be taking CS exam soon and I am just to make sure.

Thanks

Odds are that you won't see that. But if you do, might as well mention it. They won't dock you for doing it.

 

[work99]

Odds are that you won't see that. But if you do, might as well mention it. They won't dock you for doing it.

How about in PE exam, is there any lab follow-up case with diagnostic test results or lab. Do they expect us to read the study and document the result on the SOAP note? Any one having a case like this please

Thanks

 

[work99]

Any one please. Thanks

 

[TX4Lyfe]

Purely h&p and p/e documentation with ddx and diagnostic labs/imaging you'd want to order just as the cs website sample documentation form. At least that's my understanding.

I'm fairly certain that they won't have you do anything other than what's listed above. Unless someone knows something else...good luck

 

[jackieMD2007]

You guys are making this more complicated than it is.
I took CS and it was JUST LIKE what they say in FIRST AID FOR STEP 2 CS.

There is a paper with the patient's name, age, CC and vitals.
That is it. You don't read or interpret any labs, EKGs or CXR.
All you do is judge what needs to be ordered, what the differential is, and write a brief note (the forms are online and look exactly like the day of.)