mistakes in patient notes and patient encounter..

[drortho]

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Hello everybody here,
I would like to have your suggestion. I appeared for my Step 2 CS exam yesterday. But by remembering those moments I m really get frustated. I remember my mistakes and I worry abt my possible results..
My mistakes are as follows:
- I forgot to counsel about rectal/pelvic exam in a case of appendicitis. PE was complete.
- I forgot to counsel about smoking in one patient with lightheadedness.
- I didn't cover private part during abdominal exam in female patient.
- I forgot neck examination in a case with dysphagia.
- The thing most worrying me is my patient note. The mistake I committed there is using abbreviation out of the list. I used CVS for hear exam, RS for lung, BS for bowel sound, RRR for regular rate and rhythm, EOMI for extraocular movement Intact, RR for respiratory rate.
these many abbreviation I used. otherwise other findings are mentioned completely. Let me know how are my chances to fail??

 

[Golding]

By the sounds of it, your career is over. 😏



...nah.

Realistically, it's hard to say how you did just by a list of what you didn't do. Yeah, you won't get points for what you don't do, but the question is whether any of those things you didn't do are actually points being counted.

Did you counsel the appendicitis patient at all? Whether you specifically mentioned a rectal/pelvic exam outside of the note isn't particularly important, so long as you explained what you believed the problem was, why you believe that, and what you plan to do about it.

All of the abbreviations you used were fine. As long as a physician can understand what they mean (I used all of those abbreviations and more), it's no biggie.

The only significant error I noticed in your list is not covering up your patient during the abdominal exam. Sneaking peeks at the pretty actors is a no-no.
But if it happened just once, it's only 1 point on the exam anyway.

This test is more a question of what you did do, rather than what you didn't. Everyone leaves this test recalling what they forgot to do. But be reasonable with yourself. You only had so much time and so much writing space to work with. You're not going to hit every point. No one will.

 

[Doctor4Life1769]

Hell, for an acute back pain, I forgotto switch the pt from tylenol to an NSAID ... 🙄

 

[34140]

i forgot to consel 3 pts in a row about etoh/safe sex/smoking etc

and i also used EMOI, RRR, twice i used no t/m/g (thrills murmurs gallops) and a few more.

you have to remember its physcians grading the note, they know abreiviations.

i passed btw!

 

[VeerTheTIGuy]

this is all relatively reassuring to hear for someone who is taking it Monday and keeps worrying about ticking all the boxes in FA (there's NO WAY its possible...EVER!!)