Step 2 CS: differences in patient couseling versus final plan in patient note?

[mskk]

So I just took Step 2 CS yesterday. I feel like I generally did OK; however there is one thing that's concerning me. After taking the history and examining the patient, I did the counseling session where I offered several (usually 2-3) different diagnoses and the tests and/or labs that I would do at this time. I was usually able to put some thought into this during the exam, however some of it was not as well thought out as I would have liked. Then, when it came to write the patient note and I'd had more time to think, I sometimes adjusted my differential and ended up writing different diagnoses or preliminary tests in the note, than what I'd originally told the patient in the counseling session.

So, basically I'm just curious if this is a common thing to do, or if you're expected to write the patient note (differential and plan) exactly as you told the patient??

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[eastcoastdr]

Then, when it came to write the patient note and I'd had more time to think, I sometimes adjusted my differential and ended up writing different diagnoses or preliminary tests in the note, than what I'd originally told the patient in the counseling session.

So, basically I'm just curious if this is a common thing to do, or if you're expected to write the patient note (differential and plan) exactly as you told the patient??

I did the same thing during my exam. I think its perfectly natural (and expected!) to adjust your differential/plan while writing the note. During the closure part of the interview I believe the focus is more on being able to notify the patient on your findings in a professional manner,, explaining medical terminology, express empathy, asking if the patient has any questions, and all of that over accuracy. Did you make sure to tell your patient about rectal/pelvic/breast exams when that is warranted, though (and not just put it on the note)? I think those are really important diagnostic tests to bring up because it requires a little more sensitivity to talk about.

 

[mskk]

I did the same thing during my exam. I think its perfectly natural (and expected!) to adjust your differential/plan while writing the note. During the closure part of the interview I believe the focus is more on being able to notify the patient on your findings in a professional manner,, explaining medical terminology, express empathy, asking if the patient has any questions, and all of that over accuracy. Did you make sure to tell your patient about rectal/pelvic/breast exams when that is warranted, though (and not just put it on the note)? I think those are really important diagnostic tests to bring up because it requires a little more sensitivity to talk about.

OK awesome, thanks for your reply. Just wanted to make sure I wasn't crazy! And yes, I definitely notified the patient if I thought a rectal/pelvic/breast exam was necessary, as well as explained my findings/asked if they had questions/etc etc.