step 2 CS --rectals,etc

[ThinkFast007]

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on those exams that one should not do (ie rectals, paps, etc)....i know when we took a practice exam of this CS at my school the pt would hand us a piece of paper that said STOOL GUAIAC etc negative. OR do we just put it in our plan as one of the things we ought to do?

other q was...i know we have the option of typing the PN's out, but is the standard practice just writing it on the piece of paper (this is what first aid states)

Thanks
I know this was discussed somewhere on this forum..i just couldnt find it.

 

[Stinger86]

It's all personal preference, really. I typed all my notes because i'm left-handed and I smear my writing when I'm working quickly (ink doesn't have time to dry). The problem with typing is that you have a character limit that keeps you from typing too much. If you choose to type, you have to be a pro at being succinct and/or using abbreviations, or you'll experience quite a bit of frustration. I know I did.

As for the guaiac exams, if you feel one is warranted, simply tell the patient during the encounter that you think one needs to be performed soon, explain what it is and what you do with it, and then ask if that's ok. And don't forget to document it in the Plan section of the PN.