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Download the paper version of a Patient CS Note by clicking here.

Electronic Version Below

  • Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient's problem(s).
  • Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of examination you performed in this encounter.
  • Data Interpretation

    Based on what you have learned from the history and the physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)
  • Please write one history finding per line
  • Please write one physical exam finding per line
  • Please write one history finding per line
  • Please write one physical exam finding per line
  • Please write one history finding per line
  • Please write one physical exam finding per line
  • Enter one diagnostic study per line if entering multiple studies

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Placement & Roommate Info

Click here to find more information about students at different placements and to find roommates at your hospital!

Recent Articles

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