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CONTENT DESCRIPTION

and GENERAL INFORMATION

Step 2 Clinical Skills (CS)

A Joint Program of the Federation of State Medical Boards of the


United States, Inc., and the National Board of Medical Examiners®
This booklet updated November 2018.

Copyright © 2003-2018 by the Federation of State Medical Boards of the United States, Inc., and the National Board of Medical
Examiners® (NBME®). The USMLE® is a joint program of the Federation of State Medical Boards of the United States, Inc., and the
National Board of Medical Examiners. Portions reproduced with permission from the Educational Commission for Foreign Medical
Graduates (ECFMG®) Clinical Skills Assessment (CSA®) Candidate Orientation Manual, Copyright © 2002 by the ECFMG.
CONTENTS

Introduction ......................................................................................................................................................................3

Step 2 CS Cases................................................................................................................................................................4

Description of the Examination .......................................................................................................................................5

Scoring .............................................................................................................................................................................11

Rules of Conduct and Testing Regulations ...................................................................................................................13

Common Abbreviations for the Patient Note...............................................................................................................14

Appendix A: Common Presenting Signs and Symptoms ............................................................................................15

Appendix B: Patient Note Screen ..................................................................................................................................16

Appendix C: Sample Patient Note Styles ......................................................................................................................17


INTRODUCTION

This document is intended to help examinees prepare for the Results of the USMLE are reported to medical licensing
Step 2 Clinical Skills (CS) component of the United States authorities in the United States and its territories for use in
Medical Licensing Examination (USMLE®). Persons preparing to granting the initial license to practice medicine. The USMLE is
take the Step 2 CS examination should also view the orientation sponsored by the Federation of State Medical Boards (FSMB)
video, as well as the video re-enactments of examinee and the National Board of Medical Examiners (NBME®).
performances available at the USMLE website (www.usmle.org).
Step 2 of the USMLE assesses the ability of examinees to apply
Information on eligibility, registration, and scheduling is medical knowledge, skills, and understanding of clinical science
available in the USMLE Bulletin of Information, which is posted essential for the provision of patient care under supervision, and
on the USMLE website. Students and graduates of international includes emphasis on health promotion and disease prevention.
medical schools must also consult the Educational Commission Step 2 ensures that due attention is devoted to the principles of
for Foreign Medical Graduates (ECFMG®) Information Booklet clinical sciences and basic patient-centered skills that provide
on the ECFMG website (www.ecfmg.org). the foundation for the safe and effective practice of medicine.

The information in this document is available at the USMLE The two components of Step 2 are Clinical Knowledge (CK) and
website. Changes in the USMLE program may occur after the Clinical Skills (CS).
release of this document. If changes occur, information will be
posted on the USMLE website. You must obtain the most • Step 2 CK uses the multiple-choice examination format to
recent information to ensure an accurate understanding of test clinical knowledge.
current USMLE policy.
• Step 2 CS uses standardized patients to test medical
The USMLE, through its three Steps (Step 1, Step 2, and Step 3), students and graduates on their ability to be patient-
assesses a physician's ability to apply knowledge, concepts, and centered, to address the diagnostic challenges posed, to
principles, and to demonstrate fundamental patient-centered prepare the patient for next steps, and to document the
skills that are important in health and disease management and encounter appropriately.
that constitute the basis of safe and effective patient care.

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STEP 2 CS CASES

STANDARDIZED PATIENT–BASED ASSESSMENTS equitable across all examinees. On any examination day, the set
of cases will differ from the combination presented the day
The patients you will see are people trained to portray real before or the following day, but each set of cases has a
patients with a clinical problem. This method of assessment is comparable degree of difficulty.
referred to as a standardized patient examination. The
standardized patient–based testing method was established The intent is to ensure that examinees encounter a broad
more than 35 years ago, and its procedures have been tested and spectrum of cases reflecting common and important symptoms
validated in the United States and internationally. and diagnoses, as well as patients with a variety of backgrounds
and personalities. The criteria used to define the blueprint and
When you take the Step 2 CS exam, you will have the same create individual examinations focus primarily on presenting
opportunity as all other examinees to demonstrate your clinical complaints and conditions.
skills proficiency. The examination is standardized, so that all
examinees receive the same information when they ask Presentation categories include, but are not limited to,
standardized patients the same or similar questions. An ongoing cardiovascular, constitutional, gastrointestinal, genitourinary,
quality control mechanism focuses on consistency in portrayal musculoskeletal, neurological, psychiatric, respiratory, and
and scoring of the individual cases, and utilizes both observation women's health. Examinees will see cases from some, but not
of live encounters and review of digital recordings. all, of these categories. The selection of cases is also guided by
specifications relating to acuity, age, gender, and type of physical
EXAMINATION BLUEPRINT findings.

As part of the test development process, practicing physicians WHAT TO EXPECT


and medical educators develop and review cases to ensure that
they are accurate and appropriate. These cases represent the • Your Step 2 CS administration will include 12 patient
kinds of patients and problems normally encountered during encounters.
medical practice in the United States.
• Appendix A provides a list of common presenting signs and
Most cases are specifically designed to elicit patient-centered symptoms that examinees may expect to see during an
communication with methods of data collection that examination. These are examples only, and the list does not
demonstrate the examinee’s ability to relate to the patient and to represent all possible presenting signs and symptoms that
list and pursue various plausible diagnoses. may be encountered.

The cases that make up each administration of the Step 2 CS • The 12 patient encounters include a very small number of
exam are based upon an examination blueprint. An nonscored encounters, which are added for pilot testing of
examination blueprint defines the requirements for each test, new cases and other research purposes. Such cases are not
regardless of where and when it is administered. The sample of counted in determining your score.
cases selected for each exam reflects a balance of cases that is

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D E S C R I P T I O N O F T H E E X A M I N AT I O N

When you arrive at the test center on the day of your belongings, including cell phones, watches, pagers, tablet PCs,
examination, bring: iPods/media players, fitness and tracking monitors, any device
with transmitting or receiving capabilities (e.g., Bluetooth),
• The Scheduling Permit you received after your registration formulas, study materials, notes, papers, pens/pencils, and your
was completed; purse or wallet before you enter the testing room. These items
must be stored during the examination.
• Your Confirmation Notice;
ITEMS FOR INSPECTION
• An unexpired, government-issued form of identification that
includes a photograph and signature, such as a current All examinees will be required to remove eyeglasses for visual
driver's license or passport. inspection by the test center administrators. These inspections
will be brief and will be performed during the check-in process.
Your name as it appears on your Scheduling Permit must match
the name on your form(s) of identification exactly. The only Jewelry, except for wedding and engagement rings, is
acceptable differences are variations in capitalization; the prohibited. This includes tie clips and cuff links.
presence of a middle name, middle initial, or suffix on one
document and its absence on the other; or the presence of a Hair accessories are subject to inspection. Examinees should
middle name on one and middle initial on the other. not wear ornate clips, combs, barrettes, headbands, and other
hair accessories. Examinees wearing any of these items on the
If you do not bring acceptable identification, you will not be test day may be asked to store such items in their locker.
admitted to the test. In that event, you must pay a fee to
reschedule your test. Your rescheduled test date(s) must fall STORAGE OF PERSONAL ITEMS
within your assigned eligibility period.

TIME

The time you should arrive at the test center is listed on the
Confirmation Notice you will print after scheduling your
appointment.

LOCATION

Information on Clinical Skills Evaluation Collaboration (CSEC)


test centers (addresses, maps, and travel information) is
available at http://www.csecassessments.org/test-centers/.

POLICIES AND PROCEDURES

Please note that, as part of the Step 2 CS registration process,


you acknowledge and agree to abide by USMLE policies and
procedures, including those related to confidentiality. Each test center contains locked storage. You will be able to
place small personal items that you might need during breaks at
PERSONAL ITEMS your seat in the orientation room. The proctors will ask you to
put all unauthorized items into the locked storage area. Luggage
Please bring only necessary personal items with you to the may not be stored in the center.
center. You will place in a locker or cubicle all personal

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GUESTS Throughout the examination day, staff members wearing
identifying name tags will direct you through the examination.
There are no waiting facilities for spouses, family, or friends; plan You must follow their instructions at all times.
to meet them elsewhere after the examination.
EXAMINATION LENGTH
CLOTHING
Your Step 2 CS administration will include 12 patient encounters.
Wear comfortable, professional clothing and a white laboratory The examination session lasts approximately 8 hours. You will
or clinic coat. The proctors will cover with adhesive tape have 50 minutes of break time:
anything on the laboratory coat that identifies either you or your
institution. • 10-minute break after the 3rd patient encounter

EQUIPMENT • 30-minute break (which includes a light lunch) after the 6th
patient encounter
The only piece of medical equipment you may bring is an
unenhanced standard stethoscope, which is subject to • 10-minute break after the 9th patient encounter
inspection by test center staff. All other necessary medical
equipment is provided in the examination rooms. The test center is unable to accommodate special meal requests.
You may bring your own food, provided that no refrigeration or
Do not bring other medical equipment, such as reflex hammers, preparation is required. Smoking is prohibited throughout the
pen lights, or tuning forks to the test center. If you forget to bring centers.
a laboratory coat or stethoscope, a limited number of coats and
stethoscopes are available at each test center. However, it is ONSITE EQUIPMENT AND EXAMINEE INSTRUCTIONS
strongly recommended you bring your own.
The testing area of the clinical skills evaluation center consists of
ORIENTATION examination rooms equipped with standard examination tables,
commonly used diagnostic instruments (blood pressure cuffs,
otoscopes, and ophthalmoscopes), non-latex gloves, sinks, and
paper towels. Examination table heights are approximately 32-33
inches, and are not adjustable. Outside each examination room
is a cubicle equipped with a computer, where you will compose
the patient note.

There is a one-way observation window in each examination


room. These are used for quality assurance, training, and
research.

Each examination session begins promptly with an on-site WHAT TO EXPECT


orientation. If you arrive during the on-site orientation, you may be
allowed to test; however, you will be required to sign a Late • Before the first patient encounter, you will be provided with
Admission Form. If you arrive after the on-site orientation, you will a clipboard, blank paper for taking notes, and a pen.
not be allowed to test. You will have to reschedule your testing
appointment and will be required to pay the rescheduling fee. • There will be an announcement at the beginning of each
patient encounter. When you hear the announcement you
SECURITY may review the patient information posted on the
examination room door (examinee instructions). You may
The clinical skills evaluation centers are secured facilities. Once also make notes at this time. DO NOT write on the paper
you enter the secured area of the center for orientation, you may before the announcement that the patient encounter has
not leave that area until the examination is complete. begun.

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• The examinee instruction sheet gives you specific As you would when encountering real patients, respond
instructions and indicates the patient's name, age, gender, appropriately to the patients’ needs for information exchange
and reason for visiting the doctor. It also indicates his or her and understanding and engage them in planning for next steps.
vital signs, including heart rate, blood pressure, temperature
(Celsius and Fahrenheit), and respiratory rate, unless Introduce yourself as you would in a professional setting. Do not
instructions indicate otherwise. mention the name of your school or institution.

• You can accept the vital signs on the examinee instruction The information you need to obtain in each encounter will be
sheet as accurate, and do not need to repeat them unless determined by the nature of the patient’s problems. Your
you believe the case specifically requires it. For instance, you approach should be focused. You will not have time to do a
may encounter patient problems or conditions that suggest complete history and physical examination, nor will it be
the need to confirm or re-check the recorded vital signs necessary to do so. Pursue the relevant parts of the examination,
and/or perform specific maneuvers in measuring the vital based on the patient’s problems and other information you learn
signs. However, if you do repeat the vital signs, with or during the encounter.
without additional maneuvers, you should consider the vital
signs that were originally listed as accurate when developing The cases are developed to present in a manner that simulates
your differential diagnosis and work-up plan. how patients present in real clinical settings. Therefore, most
cases are designed realistically to present more than one
• You may encounter a case in which the examinee diagnostic possibility. Based on the patient's presenting
instructions include the results of a lab test. In this type of complaint and the additional information you obtain as you
patient encounter the patient is returning for a follow-up begin taking the history, you should consider all possible
appointment after undergoing testing. The doorway diagnoses and explore the relevant ones as time permits.
instructions will indicate whether, in these instances, a
physical examination is required. Brief videos depicting re-enactments by actors of actual
examinee performances on the USMLE Step 2 CS examinations
THE PATIENT ENCOUNTER are available at https://www.usmle.org/practice-
materials/index.html#tab_step2cs. The names of the examinees
You will have 15 minutes for each patient encounter. and standardized patients have been changed. All videos are
less than two minutes in length.
When you enter the room, you will encounter a standardized
patient or you will be asked to communicate with a standardized These videos provide examples of examinee performance at an
patient over the telephone. By relating to the patient in a patient- acceptable level, and may be helpful to individuals preparing to
centered manner, asking relevant questions, and performing a take the exam.
focused physical examination, you will be able to gather enough
information to develop a preliminary differential diagnosis and a If you are unsuccessful at Step 2 CS and must repeat the
diagnostic work-up plan, as well as begin to develop an effective examination, it is possible you will see similarities to cases or
physician-patient relationship. patients that you encountered on your prior attempt. Do not
assume that the underlying problems are the same or that the
Your role during the examination should be that of at least a encounter will unfold in exactly the same way. It is best to
first-year postgraduate resident physician with primary approach each encounter with an open mind, responding
responsibility for the care of each patient. You should treat each appropriately to the information provided, the history gathered,
patient you see as you would a real patient. Communicate in a and the results of the physical examination.
professional and empathetic manner, being responsive to the
patient’s needs. Do not defer decision-making to others. It may PHYSICAL EXAMINATION
be helpful to think of yourself working in a setting where you are
the only provider present. You should perform physical examination maneuvers correctly
and expect that there will be positive physical findings in some
instances. Some may be simulated, but you should accept them
as real and factor them into your evolving differential diagnoses.

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You should attend to appropriate hygiene and to patient comfort Continuing to engage the patient after the announcement to
and modesty, as you would in the care of real patients. Female stop has been made may be considered irregular behavior, will
patients will be wearing bras, which you may ask them to loosen be reported to the USMLE, and could jeopardize your continued
or move if necessary for a proper examination. participation in the USMLE program.

With real patients in a normal clinical setting, it is possible to In some cases you may complete the patient encounter in fewer
obtain meaningful information during your physical examination than 15 minutes. If so, you may leave the examination room
without being unnecessarily forceful in palpating, percussing, or early, but you are not permitted to re-enter. Be certain that you
carrying out other maneuvers that involve touching. Your have obtained all necessary information before leaving the
approach to examining standardized patients should be no examination room. Re-entering an examination room after
different. Standardized patients are subjected to repeated leaving will be considered misconduct.
physical examinations during the Step 2 CS exam; it is critical
that you apply no more than the amount of pressure that is TELEPHONE PATIENT ENCOUNTERS
appropriate during maneuvers such as abdominal examination,
examination of the gall bladder and liver, eliciting CVA Telephone patient encounters begin like all encounters; you will
tenderness, examination of the ears with an otoscope, and read a doorway instruction sheet that provides specific
examination of the throat with a tongue depressor. information about the patient. As with all patient encounters, as
soon as you hear the announcement that the encounter has
You should interact with the standardized patients as you would begun, you may make notes about the case before entering the
with any patients you may see with similar problems. The only examination room.
exception is that certain parts of the physical examination must
not be done: rectal, pelvic, genitourinary, inguinal hernia, female When you enter the room, sit at the desk in front of the
breast, or corneal reflex examinations. If you believe one or more telephone.
of these examinations are indicated, you should include them in
your proposed diagnostic work-up. • Do not dial any numbers.

Another exception is that you should not swab the standardized • To place the call, press the yellow speaker button.
patient’s throat for a throat culture. If you believe that this
diagnostic/laboratory test is indicated, include it on your • You will be permitted to make only one phone call.
proposed diagnostic workup.
• Do not touch any buttons on the phone until you are ready
All other examination maneuvers are completely acceptable, to end the call – touching any buttons may disconnect you.
including femoral pulse exam, inguinal node exam, and axillary
exam. • To end the call, press the yellow speaker button.

Excluding the restricted physical examination maneuvers, you • You will not be allowed to call back after you end the call.
should assume that you have consent to do a physical
examination on all standardized patients, unless you are Obviously, physical examination of the patient is not possible for
explicitly told not to do so as part of the examinee instructions telephone encounters, and will not be required. However, for
for that case. these cases, as for all others, you will have relevant information
and instructions and will be able to take a history and ask
Announcements will tell you when to begin the patient questions. As with other cases, you will write a patient note after
encounter, when there are 5 minutes remaining, and when the the encounter. Because no physical examination is possible for
patient encounter is over. telephone cases, leave that section of the patient note blank.

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THE PATIENT NOTE Patient notes are rated by licensed, board-certified physicians
who are well trained at reading notes and can interpret most
handwriting. However, extreme illegibility will be a problem and
can adversely impact a score. Everyone who writes patient notes
by hand should make them as legible as possible.

If you have a case for which you think no diagnostic studies are
necessary, write "No studies indicated" rather than leaving that
section blank.

You will not receive credit for listing examination procedures you
WOULD have done or questions you WOULD have asked had
the encounter been longer. Write ONLY the information you
elicited from the patient through either physical examination or
Immediately after each patient encounter, you will have 10 history taking.
minutes to complete a patient note. If you leave the patient
encounter early, you may use the additional time for the note. A countdown clock will be visible in the upper right hand corner
You will be asked to type (on a computer) a patient note similar of the patient note program screen, showing how much time
to the medical record you would compose after seeing a patient remains. An announcement will be made when two minutes
in a clinic, office, or emergency department. remain for writing the note. The countdown clock will change to
yellow when 30 seconds remain. At the end of 25 minutes, the
You should record pertinent medical history and physical note will submit automatically and examinees will not be able to
examination findings obtained during the encounter, as well as continue writing.
your initial differential diagnoses (maximum of three). The
diagnoses should be listed in order of likelihood. You should Examinees will not be permitted to handwrite the note, unless
also indicate the pertinent positive and negative findings technical difficulties on the test day make the patient note typing
obtained from the history and physical examination to support program unavailable. If that happens, it is important that you
each potential diagnosis. follow the proctor’s instruction and comply with all
announcements. If you are handwriting and an announcement is
While it is important that a physician be able to recognize made to stop writing, stop at once. Remain seated and wait for
findings that rule out certain serious or life-threatening further instructions.
diagnoses, the task for Step 2 CS examinees is to record only the
most likely diagnoses, along with findings (positive and Continuing to write after the announcement to stop has been
negative) that support them. made may be considered irregular behavior, will be reported to
the USMLE, and could jeopardize your continued participation
Finally, you will list the diagnostic studies you would order next in the USMLE program.
for that particular patient. If you think a rectal, pelvic, inguinal
hernia, genitourinary, female breast, or corneal reflex OTHER CASE FORMATS
examination, or a throat swab, would have been indicated in the
encounter, list it as part of the diagnostic studies. Treatment, The kinds of medical problems that your patients will portray are
consultations, or referrals should not be included. those you would commonly encounter in a clinic, doctor's office,
emergency department, or hospital setting. Although there are
Occasionally, due to technical or administration problems, you no young children presenting as patients, there may be cases in
will not be able to type the patient note for one or more patient which you encounter—either in the examination room or via the
encounters. When this happens, examinees will be required to telephone—a child’s parent or caregiver, or the caregiver of an
write their patient notes by hand. All examinees should be elderly patient.
prepared for the possibility that they may have to write one or
more patient notes by hand.

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In some instances you may be instructed to perform a physical You will be able to enlarge the image. During the pre-session
examination that relates to a specific medical condition, life orientation, you will have an opportunity to view a sample image
circumstance, or occupation. Synthetic models, mannequins, or on a tablet computer, and may practice enlarging the image.
simulators provide an appropriate format for assessment of
sensitive examination skills such as genital or rectal If you encounter any case for which you decide no physical
examination, and may be used for these cases. In such cases, examination is necessary, or if you are instructed not to conduct
specific instructions regarding the use of these devices will be a physical examination, leave that section of the patient note
provided. blank. In those cases where you are instructed to counsel a
patient regarding a particular medical problem or issue, you
For some cases, you may be asked to look at a digital image (for should continue to use patient-centered communication
example, a photograph, x-ray, MRI, or CT) on a tablet computer. techniques to accomplish the counseling task.

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SCORING

Step 2 CS is designed to evaluate your ability to engage in a administration in order to achieve a passing performance on
conversation that allows you to gather information relevant for a Step 2 CS.
given patient presentation, and to begin to develop an effective
physician patient relationship. The CIS subcomponent includes assessment of the patient-
centered communication skills of fostering the relationship,
• During your physical examination, you should attempt to gathering information, providing information, helping the
elicit important positive and negative signs. patient make decisions about next steps and supporting
emotions. CIS performance is assessed by the standardized
• Make sure you engage the patient in discussion of your patients, who record these skills using a checklist based on
initial diagnostic impression and the diagnostic studies you observable behaviors.
will order. The patients may ask questions, and you will see
a range of personalities and styles in asking questions and Examinees demonstrate the ability to foster the relationship by
presenting information. listening attentively, showing interest in the patient as a person,
and by demonstrating genuineness, caring, concern and respect.
• You should address each patient's concern as you would in
a normal clinical setting. Examinees demonstrate skills in gathering information by use of
open-ended techniques that encourage the patient to explain the
The ability to engage in patient-centered communication is situation in his/her own words and in a manner relevant to the
essential to safe and effective patient care. Step 2 CS is intended situation at hand, and by developing an understanding of the
to determine whether physicians seeking an initial license to expectations and priorities of the patient and/or how the health
practice medicine in the United States, regardless of country of issue has affected the patient.
origin, can communicate effectively with patients. The
standardized patients assess communication skills, Examinees demonstrate skills in providing information by use of
interpersonal skills, and English-speaking skills via carefully terms the patient can understand, and by providing reasons that
developed rating scales, for which SPs have participated in the patient can accept. These statements need to be clear and
intensive training. understandable and the words need to be those in common
usage. The amount of information provided needs to be
Your ability to document in the patient note the findings from matched to the patient’s need, preference, and ability. The
the patient encounter, diagnostic impression, and initial patient should be encouraged to develop and demonstrate a full
diagnostic studies will be rated rated based upon: and accurate understanding of key messages.

• The quality of documentation of important positive and Examinees demonstrate helping the patient make decisions by
negative findings from the history and physical examination outlining what should happen next, linked to a rationale, and by
assessing a patient’s level of agreement, willingness, and ability
• Your listed differential diagnoses, justification of those to carry out next steps.
diagnoses, and diagnostic assessment plans.
Examinees demonstrate ability to support emotions when a
SCORING OF THE STEP 2 CS SUBCOMPONENTS clinical situation warrants by seeking clarification or elaboration
of the patient’s feelings and by using statements of
USMLE Step 2 CS is a pass/fail examination. understanding and support.

Examinees are scored in three separate subcomponents: The SEP subcomponent includes assessment of clarity of
Communication and Interpersonal Skills (CIS), Spoken English spoken English communication within the context of the doctor-
Proficiency (SEP), and Integrated Clinical Encounter (ICE). Each patient encounter (for example, pronunciation, word choice, and
of the three subcomponents must be passed in a single minimizing the need to repeat questions or statements).

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SEP performance is assessed by the standardized patients using • Listing improbable diagnoses with no supporting evidence
a global rating scale, where the rating is based upon the
frequency of pronunciation or word choice errors that affect • Listing an appropriate diagnosis without listing supporting
comprehension, and the amount of listener effort required to evidence
understand the examinee's questions and responses.
• Listing diagnoses without regard to the order of likelihood
The ICE subcomponent includes assessments of both data
gathering and data interpretation skills. Scoring for this Appendix B illustrates a blank patient note screen.
subcomponent consists of a checklist completed by the
standardized patients for the physical examination portion of the Appendix C provides examples of two completed patient notes.
encounter, and global ratings provided by trained physician The samples also include annotations, highlighting actions that
raters. The patient note raters provide ratings on the would add to or lower a patient note score.
documented summary of the findings of the patient encounter
(history and physical examination), diagnostic impressions, A program for practicing typing the patient note is available on
justification of the potential diagnoses, and initial patient the USMLE website (https://www.usmle.org/step-2-cs/).
diagnostic studies.
STEP 2 CS SCORE REPORTING SCHEDULE
Although it is not feasible to list every action that might affect an
examinee’s patient note score, the descriptions below are meant Step 2 CS examinees are grouped into testing periods according
to serve as examples of actions that would add to or subtract to the dates on which they test. The first results for a given
from an examinee’s score. testing period will be issued on the first day of the
corresponding reporting period, and it is expected that results
The following are examples of actions that would result in higher for the vast majority of examinees who take the exam during the
scores: testing period will be reported on this date. However, it is
important to note that there will likely be a small number of
• Using correct medical terminology examinees for whom scoring and quality assurance are not
completed by the first day of the reporting period; these will
• Providing detailed documentation of pertinent history and typically be examinees who took the exam in the latter part of the
physical findings. For example: writing “pharynx without testing period. Results for these examinees will be reported each
exudate or erythema” is preferable to stating that the week throughout the reporting period, and should be reported
pharynx is clear. no later than the last day of the score reporting period.

• Listing only diagnoses supported by the history and findings This schedule allows USMLE staff to enhance the quality
(even if this is fewer than three) assurance and data collection/scoring procedures performed
prior to score reporting. Additionally, it provides examinees, as
• Listing the correct diagnoses in the order of likelihood, with well as others who rely on Step 2 CS results, with guidelines
the most likely diagnosis first regarding when a result will be reported for a given exam date.
These guidelines allow examinees to plan their exam registration
• Supporting diagnoses with pertinent findings obtained from and scheduling in order to have their results in time to meet
the history and physical examination specific deadlines, such as those related to graduation or
participation in the National Resident Matching Program
The following are examples of actions that would result in lower (NRMP), or "the Match." Information about testing periods and
scores on the patient note: corresponding reporting periods is available at
http://www.usmle.org/step-2-cs/#reporting.
• Using inexact, nonmedical terminology, such as pulled
muscle

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R U L E S O F C O N D U C T A N D T E S T I N G R E G U L AT I O N S

You cannot discuss the cases with your fellow examinees, • Taking or attempting to take an examination for which you
during breaks or at any time. are not eligible
• Taking an examination for someone or engaging someone
Conversation among examinees in languages other than English to take an examination for you
about any subject is strictly prohibited at all times, including • Seeking, providing, or obtaining unauthorized assistance
during breaks. Test center staff will be with you to monitor during the examination or attempting to do so
activity. To maintain security and quality assurance, each • Making notes of any kind while in the secure areas of the
examination room is equipped with video cameras and test center, except on the writing materials provided at the
microphones to record every patient encounter. test center for this purpose
• Failing to adhere to any USMLE policy, procedure, or rule,
The USMLE program retains the right to remove any examinee including instructions of the test center staff
from the examination who appears to represent a health or • Verbal or physical harassment of test center staff or other
safety risk to the standardized patients or staff of a clinical skills examination staff, or other disruptive or unprofessional
evaluation center. This includes, but is not limited to, examinees behavior during the registration, scheduling, or examination
who appear ill, are persistently coughing or sneezing, have open process
skin lesions, or have evidence of active bleeding. Examinees who • Possessing any unauthorized materials, including
are not feeling well are encouraged to seek medical advice prior photographic equipment, communication or recording
to arrival at the center and, if consistent with medical advice, devices, fitness and tracking monitors, and cell phones, in
should consider rescheduling the date of their examination. This the secure testing areas
can be done at the website of your registration entity. • Altering or misrepresenting examination scores
• Unauthorized reproduction by any means, including, but
Clinical skills evaluation center staff monitor all testing not limited to, reconstruction through memorization,
administrations for the Step 2 CS examination. You must follow and/or dissemination of copyrighted examination materials
instructions of test center staff throughout the examination. by any means, including the Internet
Failure to do so may result in a determination of irregular • Communicating or attempting to communicate about
behavior. The USMLE Bulletin of Information provides a specific test items, cases, and/or answers with another
complete description of irregular behavior and the examinee, potential examinee, or formal or informal test
consequences of a finding of irregular behavior in the sections preparation group at any time before, during, or after an
titled Testing Regulations and Rules of Conduct and Irregular examination
Behavior. You must become familiar with the Bulletin of • Failure to cooperate fully in any investigation of a violation
Information before you take your examination. of the USMLE rules
• Interacting with any standardized patient outside of that
Irregular behavior includes any action by applicants, examinees, standardized patient's given case portrayal, before, during,
potential applicants, or others when solicited by an applicant or after the examination
and/or examinee that subverts or attempts to subvert the • Conversing with other Step 2 CS examinees in any language
examination process. Specific examples of irregular behavior other than English at any time while at the test center
include, but are not limited to: • Engaging in behaviors that could constitute a real or
potential threat to a patient’s safety, such as careless or
• Seeking, providing, and/or obtaining unauthorized access to dangerous actions during physical examination.
examination materials
• Providing false information or making false statements on Instances of possible irregular behavior are thoroughly
or in connection with application forms, scheduling investigated and actions may be taken under the USMLE policies
permits, or other USMLE-related documents and procedures on irregular behavior.

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C O M M O N A B B R E V I AT I O N S F O R T H E P AT I E N T N O T E

Lists similar to the one below will be available on-site for reference during Step 2 CS administrations.

Note: This is not intended to be a complete list of acceptable abbreviations, but rather represents the types of common abbreviations that may be
used on the patient note. There is no need to use abbreviations on the patient note; if you are in doubt about the correct abbreviation, write it out.

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APPENDIX A
Common Presenting Signs and Symptoms
Please note that this list shows examples, and does not represent all possible presenting signs and symptoms that may be
encountered during a Step 2 Clinical Skills examination.

Abdominal distension Irritable infant/child


Abdominal pain Jaundice
Abnormal menses Jaw pain
Abnormal movements Joint pain
Altered bowel habits Joint swelling
(e.g., constipation, diarrhea, fecal incontinence) Leg swelling
Back pain Loss of appetite
Bloody stools/melena Mass/lump
Breast-related complaints Memory loss
Chest pain/discomfort Mood disorder
Child and adolescent behavior concerns Mouth and lip changes
Confusion Muscle pain
Cough Nasal discharge
Decreased sensation in extremities Nausea/vomiting
Dental pain Neck pain
Difficulty walking Palpitations
Dyspareunia Post-operative complications
Dysphagia Postpartum concerns/complications
Ear-related complaints Pregnancy-related concerns/complications
(e.g., pain, tinnitus, hearing loss) Pruritus
Easy bruising Rash
Epistaxis Seizure
Evaluation after a fall Sexual dysfunction
Extremity pain Shortness of breath
Eye complaints (e.g., pain, visual changes) Sinus pain/pressure
Fatigue Sleep issues
Fevers, chills and/or night sweats Sore throat
Flank pain Substance use
Genital complaints (e.g., discharge, lesions, pain) Syncope
Hallucinations Trouble concentrating
Headache Urinary complaints
Hematemesis (e.g., frequency, dysuria, retention, incontinence)
Hemoptysis Vertigo/dizziness/lightheadedness
High blood pressure Weakness
Hot flashes Weight gain
Indigestion Weight loss
Infant spitting up Wheezing

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APPENDIX B
Patient Note Screen
When you type the patient note, you will use a program similar to the one pictured below. You can practice using the patient note
software by using the program provided at the USMLE website (www.usmle.org). The patient note screen that appears during the
actual examination will have a status bar for each field, indicating how much space remains.

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APPENDIX C
Sample Patient Note Styles
Various styles of writing patient notes for the Step 2 CS examination are acceptable. Two examples of patient notes are shown on the
following pages. These examples are not meant to represent ideal or perfect patient notes, nor should they be assumed to be
complete or accurate with respect to content. Both, however, would be considered acceptable. In addition, guidelines to help
examinees understand patient note scoring are provided in callouts.

NOTE: The History and Physical Examination fields within the patient note program accept a maximum of 15 lines of typing
OR 950 characters.

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Patient Note Example 1

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Patient Note Example 1 (continued)

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Patient Note Example 2

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Patient Note Example 2 (continued)

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