Last Minute Help Needed For Cs

[Thaitanium]

Hi all-

I have my CS tomm afternoon and had a last minute question.

I was wondering in case you do not perform a physical exam technique (ie. fundoscopy) or you did not tell the patient you were going to order X test, can you still write it in the patient note and receive credit for it?

Thanks for any help.

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[Bertelman]

Hi all-

I have my CS tomm afternoon and had a last minute question.

I was wondering in case you do not perform a physical exam technique (ie. fundoscopy) or you did not tell the patient you were going to order X test, can you still write it in the patient note and receive credit for it?

Thanks for any help.

I wondered the same. I'd say throw it in the note anyways. I don't think they take points off for stuff in the note. Like, guy comes in with sore throat and fever and you order head CT. CT not necessary, but you don't lose points for saying so.

Worst case, someone actually has the time and energy to compare your clinic note to the SPs report. So they find that you ordered a HIDA but it wasn't noted by the SP. You could easily argue they forgot to include it in their report. Point is, just throw it in there. There's a fair chance you won't receive credit, but I doubt you will have points counted against. I think they would have had to have warned students of this possibility in the materials, and I didn't see it anywhere.

Having said that, I wouldn't take the tack of neglecting certain time-intensive PE tasks on every encounter, and claiming you performed them in the note. I think a habit such as this on every encounter might raise a flag. But I think a couple of inconsistencies won't hurt you.