How are the CS patient notes graded?

[devildoc2]

Can I use a ton of abbreviations on the HPI or am I supposed to use proper written english?

Are they mainly grading the diff dx and treatment plan? Or are they also grading how much info you put in your HPI/ROS?

Do they expect you to write down every single ROS finding, even if its totally non-relevant to the patient's issue? What about social stuff like alcohol/drug abuse? If its negative, do I have to write it down regardless?

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[DoctorWannaBe]

Can I use a ton of abbreviations on the HPI or am I supposed to use proper written english?

Are they mainly grading the diff dx and treatment plan? Or are they also grading how much info you put in your HPI/ROS?

Do they expect you to write down every single ROS finding, even if its totally non-relevant to the patient's issue? What about social stuff like alcohol/drug abuse? If its negative, do I have to write it down regardless?

Have you looked at First Aid for Step 2 CS or the orientation materials on the USMLE website? It explains how to do a patient note. There is a list of approved abbreviations that you can use in your note. Otherwise, you need to write it out unless you are pretty sure that it is a common abbreviation that a physician will understand.

As for content, you should only include pertinent positives and negatives in your note. Whether you hand write or type your note, you will only have a limited amount of space. I always included the alcohol/tobacco/drug stuff in the note. You should always ask about alcohol/tobacco and get a sexual history and counsel them if necessary. You are supposed to counsel each patient on something, even if it has nothing to do with the chief complaint.