Note Taking During CS

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TrynaBeADoc

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During the CS exam are you allowed to take notes before entering the room? Lets say the CC is headache. Am I allowed to write on my paper things such as fundoscopic exam, trauma, light sensitivity, etc just to help remind me to do those things/ask those questions?

I can't see myself remembering everything to ask unless i take 20-30 seconds to write them down. Any advice would be greatly appreciated!
 
Once they announce that you may enter the room, the timer begins. You can basically spend the allotted time however you want, you are allowed to spend as much time as you want outside. I do recommend writing things down to organize yourself. I wrote the SMASH FM pneumonic in big letters in my paper, so that I didn't forget to ask anything and didn't have to keep a mental checklist of everything I had asked.
 
I would recommend writing some stuff on the paper they give you prior to entering the room. It lets you gather your thoughts and enter the room intelligently. Also, I was told the test awards thoroughness over specifics. So getting the whole history rather than a really specific HPI is beneficial - so figure out your favorite mnemonic and make sure you hit all the points in the patient history!
 
^ i agree with above, in addition to geting the HPI i did PAM HUGS FOSS WT for every patient, have a system so you dont miss out any of those easy questions, also helps with writing the patient note.
 
^ i agree with above, in addition to geting the HPI i did PAM HUGS FOSS WT for every patient, have a system so you dont miss out any of those easy questions, also helps with writing the patient note.

My advice, is to write the Pts name on your sheet, vital signs, pam hugs foss, and a list of 5 diff dx before entering the room. Like if the CC headache, write Migraine,Tension,SAH,Tumor,Sinusitis. That way you can kind of direct yourself during the encounter. I spent 45-60sec at the door for each pt, before entering and starting the encounter. Good Luck
 
My advice, is to write the Pts name on your sheet, vital signs, pam hugs foss, and a list of 5 diff dx before entering the room. Like if the CC headache, write Migraine,Tension,SAH,Tumor,Sinusitis. That way you can kind of direct yourself during the encounter. I spent 45-60sec at the door for each pt, before entering and starting the encounter. Good Luck

This is basically exactly as I did it. Worked well.
 
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