Step 2 CS - forget to ask pt, but include in note?

[ultane123]

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what happens if you forget to check for JVD in suspected CHF, but include it in your note because you remembered it once you left the room? do they correlate your actual patient encounter with your written note?

has anyone done this and PASSED?

thanks
ultane.

 

[lord_jeebus]

Who knows. Why would you do something that would get you in trouble in real life?

Just include it in the DDx and move on. Everyone is going to forget some things.

 

[lankysudanese]

Why would you do something that would get you in trouble in real life?

I agree: documenting false findings could only lead to a career of multiple law suits - not to mention how many patients' outcomes will be affected.

The examiners will not take such lack of professional integrity lightly (especially since it is a licensure exam)

 

[CanIMakeIt]

My advise..whats done is done but please don't do that again....you might have to face grave consequences if you are ever caught.
I don't know how true that is but I was told that someone in my class has to repeat surgery block because they made up data/PE when they had not even seen the patient that morning.
Good luck.

 

[NuMD97]

My advise..whats done is done but please don't do that again....you might have to face grave consequences if you are ever caught.
I don't know how true that is but I was told that someone in my class has to repeat surgery block because they made up data/PE when they had not even seen the patient that morning.
Good luck.

My favorite story is an attending who wrote a PN with exam findings (albeit wedged between my note and the nurse's note) one and a half hours after I had already pronounced the patient. His note wrote that we should continue the present course of management.

Didja happen to hear my jaw drop and hit the floor with a very pronounced thud where you are?😱

Nu

 

[Samoa]

The guy next to me when I took CS was making up exam findings for things he'd forgotten to do. I'm 99% certain he passed. I was royally pissed off, let me tell you.

But it's certainly easy to get away with: the person grading the note doesn't get to see your patient encounter, and the person grading your patient encounter never sees your note.