Step 2 Clinical Skills (CS)

CONTENT DESCRIPTION and GENERAL INFORMATION

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

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This document is intended to help examinees prepare for theStep 2 Clinical Skills (CS) component of the United StatesMedical Licensing Examination (USMLE®). Persons preparing totake the Step 2 CS examination should also view the orientationvideo, as well as the video re-enactments of examineeperformances available at the USMLE website (www.usmle.org).

Information on eligibility, registration, and scheduling isavailable in the USMLE Bulletin of Information, which is postedon the USMLE website. Students and graduates of internationalmedical schools must also consult the Educational Commissionfor Foreign Medical Graduates (ECFMG®) Information Bookleton the ECFMG website (www.ecfmg.org).

The information in this document is available at the USMLEwebsite. Changes in the USMLE program may occur after therelease of this document. If changes occur, information will beposted on the USMLE website. You must obtain the mostrecent information to ensure an accurate understanding ofcurrent USMLE policy.

The USMLE, through its three Steps (Step 1, Step 2, and Step 3),assesses a physician's ability to apply knowledge, concepts, andprinciples, and to demonstrate fundamental patient-centeredskills that are important in health and disease management andthat constitute the basis of safe and effective patient care.

Results of the USMLE are reported to medical licensingauthorities in the United States and its territories for use ingranting the initial license to practice medicine. The USMLE issponsored by the Federation of State Medical Boards (FSMB)and the National Board of Medical Examiners (NBME®).

Step 2 of the USMLE assesses the ability of examinees to applymedical knowledge, skills, and understanding of clinical scienceessential for the provision of patient care under supervision, andincludes emphasis on health promotion and disease prevention.Step 2 ensures that due attention is devoted to the principles ofclinical sciences and basic patient-centered skills that providethe foundation for the safe and effective practice of medicine.

The two components of Step 2 are Clinical Knowledge (CK) andClinical Skills (CS).

• Step 2 CK uses the multiple-choice examination format totest clinical knowledge.

• Step 2 CS uses standardized patients to test medicalstudents and graduates on their ability to be patient-centered, to address the diagnostic challenges posed, toprepare the patient for next steps, and to document theencounter appropriately.

STEP 2 CS CASES

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STANDARDIZED PATIENT–BASED ASSESSMENTS

The patients you will see are people trained to portray realpatients with a clinical problem. This method of assessment isreferred to as a standardized patient examination. Thestandardized patient–based testing method was establishedmore than 35 years ago, and its procedures have been tested andvalidated in the United States and internationally.

When you take the Step 2 CS exam, you will have the sameopportunity as all other examinees to demonstrate your clinicalskills proficiency. The examination is standardized, so that allexaminees receive the same information when they askstandardized patients the same or similar questions. An ongoingquality control mechanism focuses on consistency in portrayaland scoring of the individual cases, and utilizes both observationof live encounters and review of digital recordings.

EXAMINATION BLUEPRINT

As part of the test development process, practicing physiciansand medical educators develop and review cases to ensure thatthey are accurate and appropriate. These cases represent thekinds of patients and problems normally encountered duringmedical practice in the United States.

Most cases are specifically designed to elicit patient-centeredcommunication with methods of data collection thatdemonstrate the examinee’s ability to relate to the patient and tolist and pursue various plausible diagnoses.

The cases that make up each administration of the Step 2 CSexam are based upon an examination blueprint. Anexamination blueprint defines the requirements for each test,regardless of where and when it is administered. The sample ofcases selected for each exam reflects a balance of cases that is

equitable across all examinees. On any examination day, the setof cases will differ from the combination presented the daybefore or the following day, but each set of cases has acomparable degree of difficulty.

The intent is to ensure that examinees encounter a broadspectrum of cases reflecting common and important symptomsand diagnoses, as well as patients with a variety of backgroundsand personalities. The criteria used to define the blueprint andcreate individual examinations focus primarily on presentingcomplaints and conditions.

Presentation categories include, but are not limited to,cardiovascular, constitutional, gastrointestinal, genitourinary,musculoskeletal, neurological, psychiatric, respiratory, andwomen's health. Examinees will see cases from some, but notall, of these categories. The selection of cases is also guided byspecifications relating to acuity, age, gender, and type of physicalfindings.

WHAT TO EXPECT

• Your Step 2 CS administration will include 12 patientencounters.

• Appendix A provides a list of common presenting signs andsymptoms that examinees may expect to see during anexamination. These are examples only, and the list does notrepresent all possible presenting signs and symptoms thatmay be encountered.

• The 12 patient encounters include a very small number ofnonscored encounters, which are added for pilot testing ofnew cases and other research purposes. Such cases are notcounted in determining your score.

DESCRIPTION OF THE EXAMINATION

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When you arrive at the test center on the day of yourexamination, bring:

• The Scheduling Permit you received after your registrationwas completed;

• Your Confirmation Notice;

• An unexpired, government-issued form of identification thatincludes a photograph and signature, such as a currentdriver's license or passport.

Your name as it appears on your Scheduling Permit must matchthe name on your form(s) of identification exactly. The onlyacceptable differences are variations in capitalization; thepresence of a middle name, middle initial, or suffix on onedocument and its absence on the other; or the presence of amiddle name on one and middle initial on the other.

If you do not bring acceptable identification, you will not beadmitted to the test. In that event, you must pay a fee toreschedule your test. Your rescheduled test date(s) must fallwithin your assigned eligibility period.

TIME

The time you should arrive at the test center is listed on theConfirmation Notice you will print after scheduling yourappointment.

LOCATION

Information on Clinical Skills Evaluation Collaboration (CSEC)test centers (addresses, maps, and travel information) isavailable 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 andprocedures, including those related to confidentiality.

PERSONAL ITEMS

Please bring only necessary personal items with you to thecenter. You will place in a locker or cubicle all personal

belongings, including cell phones, watches, pagers, tablet PCs,iPods/media players, fitness and tracking monitors, any devicewith transmitting or receiving capabilities (e.g., Bluetooth),formulas, study materials, notes, papers, pens/pencils, and yourpurse or wallet before you enter the testing room. These itemsmust be stored during the examination.

ITEMS FOR INSPECTION

All examinees will be required to remove eyeglasses for visualinspection by the test center administrators. These inspectionswill be brief and will be performed during the check-in process.

Jewelry, except for wedding and engagement rings, isprohibited. This includes tie clips and cuff links.

Hair accessories are subject to inspection. Examinees shouldnot wear ornate clips, combs, barrettes, headbands, and otherhair accessories. Examinees wearing any of these items on thetest day may be asked to store such items in their locker.

STORAGE OF PERSONAL ITEMS

Each test center contains locked storage. You will be able toplace small personal items that you might need during breaks atyour seat in the orientation room. The proctors will ask you toput all unauthorized items into the locked storage area. Luggagemay not be stored in the center.

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GUESTS

There are no waiting facilities for spouses, family, or friends; planto meet them elsewhere after the examination.

CLOTHING

Wear comfortable, professional clothing and a white laboratoryor clinic coat. The proctors will cover with adhesive tapeanything on the laboratory coat that identifies either you or yourinstitution.

EQUIPMENT

The only piece of medical equipment you may bring is anunenhanced standard stethoscope, which is subject toinspection by test center staff. All other necessary medicalequipment is provided in the examination rooms.

Do not bring other medical equipment, such as reflex hammers,pen lights, or tuning forks to the test center. If you forget to bringa laboratory coat or stethoscope, a limited number of coats andstethoscopes are available at each test center. However, it isstrongly recommended you bring your own.

ORIENTATION

Each examination session begins promptly with an on-siteorientation. If you arrive during the on-site orientation, you may beallowed to test; however, you will be required to sign a LateAdmission Form. If you arrive after the on-site orientation, you willnot be allowed to test. You will have to reschedule your testingappointment and will be required to pay the rescheduling fee.

SECURITY

The clinical skills evaluation centers are secured facilities. Onceyou enter the secured area of the center for orientation, you maynot leave that area until the examination is complete.

Throughout the examination day, staff members wearingidentifying name tags will direct you through the examination.You must follow their instructions at all times.

EXAMINATION LENGTH

Your Step 2 CS administration will include 12 patient encounters.The examination session lasts approximately 8 hours. You willhave 50 minutes of break time:

• 10-minute break after the 3rd patient encounter

• 30-minute break (which includes a light lunch) after the 6thpatient encounter

• 10-minute break after the 9th patient encounter

The test center is unable to accommodate special meal requests.You may bring your own food, provided that no refrigeration orpreparation is required. Smoking is prohibited throughout thecenters.

ONSITE EQUIPMENT AND EXAMINEE INSTRUCTIONS

The testing area of the clinical skills evaluation center consists ofexamination rooms equipped with standard examination tables,commonly used diagnostic instruments (blood pressure cuffs,otoscopes, and ophthalmoscopes), non-latex gloves, sinks, andpaper towels. Examination table heights are approximately 32-33inches, and are not adjustable. Outside each examination roomis a cubicle equipped with a computer, where you will composethe patient note.

There is a one-way observation window in each examinationroom. These are used for quality assurance, training, andresearch.

WHAT TO EXPECT

• Before the first patient encounter, you will be provided witha clipboard, blank paper for taking notes, and a pen.

• There will be an announcement at the beginning of eachpatient encounter. When you hear the announcement youmay review the patient information posted on theexamination room door (examinee instructions). You mayalso make notes at this time. DO NOT write on the paperbefore the announcement that the patient encounter hasbegun.

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• The examinee instruction sheet gives you specificinstructions and indicates the patient's name, age, gender,and reason for visiting the doctor. It also indicates his or hervital signs, including heart rate, blood pressure, temperature(Celsius and Fahrenheit), and respiratory rate, unlessinstructions indicate otherwise.

• You can accept the vital signs on the examinee instructionsheet as accurate, and do not need to repeat them unlessyou believe the case specifically requires it. For instance, youmay encounter patient problems or conditions that suggestthe need to confirm or re-check the recorded vital signsand/or perform specific maneuvers in measuring the vitalsigns. However, if you do repeat the vital signs, with orwithout additional maneuvers, you should consider the vitalsigns that were originally listed as accurate when developingyour differential diagnosis and work-up plan.

• You may encounter a case in which the examineeinstructions include the results of a lab test. In this type ofpatient encounter the patient is returning for a follow-upappointment after undergoing testing. The doorwayinstructions will indicate whether, in these instances, aphysical examination is required.

THE PATIENT ENCOUNTER

You will have 15 minutes for each patient encounter.

When you enter the room, you will encounter a standardizedpatient or you will be asked to communicate with a standardizedpatient over the telephone. By relating to the patient in a patient-centered manner, asking relevant questions, and performing afocused physical examination, you will be able to gather enoughinformation to develop a preliminary differential diagnosis and adiagnostic work-up plan, as well as begin to develop an effectivephysician-patient relationship.

Your role during the examination should be that of at least afirst-year postgraduate resident physician with primaryresponsibility for the care of each patient. You should treat eachpatient you see as you would a real patient. Communicate in aprofessional and empathetic manner, being responsive to thepatient’s needs. Do not defer decision-making to others. It maybe helpful to think of yourself working in a setting where you arethe only provider present.

As you would when encountering real patients, respondappropriately to the patients’ needs for information exchangeand understanding and engage them in planning for next steps.

Introduce yourself as you would in a professional setting. Do notmention the name of your school or institution.

The information you need to obtain in each encounter will bedetermined by the nature of the patient’s problems. Yourapproach should be focused. You will not have time to do acomplete history and physical examination, nor will it benecessary to do so. Pursue the relevant parts of the examination,based on the patient’s problems and other information you learnduring the encounter.

The cases are developed to present in a manner that simulateshow patients present in real clinical settings. Therefore, mostcases are designed realistically to present more than onediagnostic possibility. Based on the patient's presentingcomplaint and the additional information you obtain as youbegin taking the history, you should consider all possiblediagnoses and explore the relevant ones as time permits.

Brief videos depicting re-enactments by actors of actualexaminee performances on the USMLE Step 2 CS examinationsare available at https://www.usmle.org/practice-materials/index.html#tab_step2cs. The names of the examineesand standardized patients have been changed. All videos areless than two minutes in length.

These videos provide examples of examinee performance at anacceptable level, and may be helpful to individuals preparing totake the exam.

If you are unsuccessful at Step 2 CS and must repeat theexamination, it is possible you will see similarities to cases orpatients that you encountered on your prior attempt. Do notassume that the underlying problems are the same or that theencounter will unfold in exactly the same way. It is best toapproach each encounter with an open mind, respondingappropriately to the information provided, the history gathered,and the results of the physical examination.

PHYSICAL EXAMINATION

You should perform physical examination maneuvers correctlyand expect that there will be positive physical findings in someinstances. Some may be simulated, but you should accept themas real and factor them into your evolving differential diagnoses.

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You should attend to appropriate hygiene and to patient comfortand modesty, as you would in the care of real patients. Femalepatients will be wearing bras, which you may ask them to loosenor move if necessary for a proper examination.

With real patients in a normal clinical setting, it is possible toobtain meaningful information during your physical examinationwithout being unnecessarily forceful in palpating, percussing, orcarrying out other maneuvers that involve touching. Yourapproach to examining standardized patients should be nodifferent. Standardized patients are subjected to repeatedphysical examinations during the Step 2 CS exam; it is criticalthat you apply no more than the amount of pressure that isappropriate during maneuvers such as abdominal examination,examination of the gall bladder and liver, eliciting CVAtenderness, examination of the ears with an otoscope, andexamination of the throat with a tongue depressor.

You should interact with the standardized patients as you wouldwith any patients you may see with similar problems. The onlyexception is that certain parts of the physical examination mustnot be done: rectal, pelvic, genitourinary, inguinal hernia, femalebreast, or corneal reflex examinations. If you believe one or moreof these examinations are indicated, you should include them inyour proposed diagnostic work-up.

Another exception is that you should not swab the standardizedpatient’s throat for a throat culture. If you believe that thisdiagnostic/laboratory test is indicated, include it on yourproposed diagnostic workup.

All other examination maneuvers are completely acceptable,including femoral pulse exam, inguinal node exam, and axillaryexam.

Excluding the restricted physical examination maneuvers, youshould assume that you have consent to do a physicalexamination on all standardized patients, unless you areexplicitly told not to do so as part of the examinee instructionsfor that case.

Announcements will tell you when to begin the patientencounter, when there are 5 minutes remaining, and when thepatient encounter is over.

Continuing to engage the patient after the announcement tostop has been made may be considered irregular behavior, willbe reported to the USMLE, and could jeopardize your continuedparticipation in the USMLE program.

In some cases you may complete the patient encounter in fewerthan 15 minutes. If so, you may leave the examination roomearly, but you are not permitted to re-enter. Be certain that youhave obtained all necessary information before leaving theexamination room. Re-entering an examination room afterleaving will be considered misconduct.

TELEPHONE PATIENT ENCOUNTERS

Telephone patient encounters begin like all encounters; you willread a doorway instruction sheet that provides specificinformation about the patient. As with all patient encounters, assoon as you hear the announcement that the encounter hasbegun, you may make notes about the case before entering theexamination room.

When you enter the room, sit at the desk in front of thetelephone.

• Do not dial any numbers.

• To place the call, press the yellow speaker button.

• You will be permitted to make only one phone call.

• Do not touch any buttons on the phone until you are readyto end the call – touching any buttons may disconnect you.

• To end the call, press the yellow speaker button.

• You will not be allowed to call back after you end the call.

Obviously, physical examination of the patient is not possible fortelephone encounters, and will not be required. However, forthese cases, as for all others, you will have relevant informationand instructions and will be able to take a history and askquestions. As with other cases, you will write a patient note afterthe encounter. Because no physical examination is possible fortelephone cases, leave that section of the patient note blank.

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THE PATIENT NOTE

Immediately after each patient encounter, you will have 10minutes to complete a patient note. If you leave the patientencounter early, you may use the additional time for the note.You will be asked to type (on a computer) a patient note similarto the medical record you would compose after seeing a patientin a clinic, office, or emergency department.

You should record pertinent medical history and physicalexamination findings obtained during the encounter, as well asyour initial differential diagnoses (maximum of three). Thediagnoses should be listed in order of likelihood. You shouldalso indicate the pertinent positive and negative findingsobtained from the history and physical examination to supporteach potential diagnosis.

While it is important that a physician be able to recognizefindings that rule out certain serious or life-threateningdiagnoses, the task for Step 2 CS examinees is to record only themost likely diagnoses, along with findings (positive andnegative) that support them.

Finally, you will list the diagnostic studies you would order nextfor that particular patient. If you think a rectal, pelvic, inguinalhernia, genitourinary, female breast, or corneal reflexexamination, or a throat swab, would have been indicated in theencounter, list it as part of the diagnostic studies. Treatment,consultations, or referrals should not be included.

Occasionally, due to technical or administration problems, youwill not be able to type the patient note for one or more patientencounters. When this happens, examinees will be required towrite their patient notes by hand. All examinees should beprepared for the possibility that they may have to write one ormore patient notes by hand.

Patient notes are rated by licensed, board-certified physicianswho are well trained at reading notes and can interpret mosthandwriting. However, extreme illegibility will be a problem andcan adversely impact a score. Everyone who writes patient notesby hand should make them as legible as possible.

If you have a case for which you think no diagnostic studies arenecessary, write "No studies indicated" rather than leaving thatsection blank.

You will not receive credit for listing examination procedures youWOULD have done or questions you WOULD have asked hadthe encounter been longer. Write ONLY the information youelicited from the patient through either physical examination orhistory taking.

A countdown clock will be visible in the upper right hand cornerof the patient note program screen, showing how much timeremains. An announcement will be made when two minutesremain for writing the note. The countdown clock will change toyellow when 30 seconds remain. At the end of 25 minutes, thenote will submit automatically and examinees will not be able tocontinue writing.

Examinees will not be permitted to handwrite the note, unlesstechnical difficulties on the test day make the patient note typingprogram unavailable. If that happens, it is important that youfollow the proctor’s instruction and comply with allannouncements. If you are handwriting and an announcement ismade to stop writing, stop at once. Remain seated and wait forfurther instructions.

Continuing to write after the announcement to stop has beenmade may be considered irregular behavior, will be reported tothe USMLE, and could jeopardize your continued participationin the USMLE program.

OTHER CASE FORMATS

The kinds of medical problems that your patients will portray arethose you would commonly encounter in a clinic, doctor's office,emergency department, or hospital setting. Although there areno young children presenting as patients, there may be cases inwhich you encounter—either in the examination room or via thetelephone—a child’s parent or caregiver, or the caregiver of anelderly patient.

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In some instances you may be instructed to perform a physicalexamination that relates to a specific medical condition, lifecircumstance, or occupation. Synthetic models, mannequins, orsimulators provide an appropriate format for assessment ofsensitive examination skills such as genital or rectalexamination, and may be used for these cases. In such cases,specific instructions regarding the use of these devices will beprovided.

For some cases, you may be asked to look at a digital image (forexample, a photograph, x-ray, MRI, or CT) on a tablet computer.

You will be able to enlarge the image. During the pre-sessionorientation, you will have an opportunity to view a sample imageon a tablet computer, and may practice enlarging the image.

If you encounter any case for which you decide no physicalexamination is necessary, or if you are instructed not to conducta physical examination, leave that section of the patient noteblank. In those cases where you are instructed to counsel apatient regarding a particular medical problem or issue, youshould continue to use patient-centered communicationtechniques to accomplish the counseling task.

SCORING

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Step 2 CS is designed to evaluate your ability to engage in aconversation that allows you to gather information relevant for agiven patient presentation, and to begin to develop an effectivephysician patient relationship.

• During your physical examination, you should attempt toelicit important positive and negative signs.

• Make sure you engage the patient in discussion of yourinitial diagnostic impression and the diagnostic studies youwill order. The patients may ask questions, and you will seea range of personalities and styles in asking questions andpresenting information.

• You should address each patient's concern as you would ina normal clinical setting.

The ability to engage in patient-centered communication isessential to safe and effective patient care. Step 2 CS is intendedto determine whether physicians seeking an initial license topractice medicine in the United States, regardless of country oforigin, can communicate effectively with patients. Thestandardized patients assess communication skills,interpersonal skills, and English-speaking skills via carefullydeveloped rating scales, for which SPs have participated inintensive training.

Your ability to document in the patient note the findings fromthe patient encounter, diagnostic impression, and initialdiagnostic studies will be rated rated based upon:

• The quality of documentation of important positive andnegative findings from the history and physical examination

• Your listed differential diagnoses, justification of thosediagnoses, and diagnostic assessment plans.

SCORING OF THE STEP 2 CS SUBCOMPONENTS

USMLE Step 2 CS is a pass/fail examination.

Examinees are scored in three separate subcomponents:Communication and Interpersonal Skills (CIS), Spoken EnglishProficiency (SEP), and Integrated Clinical Encounter (ICE). Eachof the three subcomponents must be passed in a single

administration in order to achieve a passing performance onStep 2 CS.

The CIS subcomponent includes assessment of the patient-centered communication skills of fostering the relationship,gathering information, providing information, helping thepatient make decisions about next steps and supportingemotions. CIS performance is assessed by the standardizedpatients, who record these skills using a checklist based onobservable behaviors.

Examinees demonstrate the ability to foster the relationship bylistening attentively, showing interest in the patient as a person,and by demonstrating genuineness, caring, concern and respect.

Examinees demonstrate skills in gathering information by use ofopen-ended techniques that encourage the patient to explain thesituation in his/her own words and in a manner relevant to thesituation at hand, and by developing an understanding of theexpectations and priorities of the patient and/or how the healthissue has affected the patient.

Examinees demonstrate skills in providing information by use ofterms the patient can understand, and by providing reasons thatthe patient can accept. These statements need to be clear andunderstandable and the words need to be those in commonusage. The amount of information provided needs to bematched to the patient’s need, preference, and ability. Thepatient should be encouraged to develop and demonstrate a fulland accurate understanding of key messages.

Examinees demonstrate helping the patient make decisions byoutlining what should happen next, linked to a rationale, and byassessing a patient’s level of agreement, willingness, and abilityto carry out next steps.

Examinees demonstrate ability to support emotions when aclinical situation warrants by seeking clarification or elaborationof the patient’s feelings and by using statements ofunderstanding and support.

The SEP subcomponent includes assessment of clarity ofspoken English communication within the context of the doctor-patient encounter (for example, pronunciation, word choice, andminimizing the need to repeat questions or statements).

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SEP performance is assessed by the standardized patients usinga global rating scale, where the rating is based upon thefrequency of pronunciation or word choice errors that affectcomprehension, and the amount of listener effort required tounderstand the examinee's questions and responses.

The ICE subcomponent includes assessments of both datagathering and data interpretation skills. Scoring for thissubcomponent consists of a checklist completed by thestandardized patients for the physical examination portion of theencounter, and global ratings provided by trained physicianraters. The patient note raters provide ratings on thedocumented summary of the findings of the patient encounter(history and physical examination), diagnostic impressions,justification of the potential diagnoses, and initial patientdiagnostic studies.

Although it is not feasible to list every action that might affect anexaminee’s patient note score, the descriptions below are meantto serve as examples of actions that would add to or subtractfrom an examinee’s score.

The following are examples of actions that would result in higherscores:

• Using correct medical terminology

• Providing detailed documentation of pertinent history andphysical findings. For example: writing “pharynx withoutexudate or erythema” is preferable to stating that thepharynx is clear.

• Listing only diagnoses supported by the history and findings(even if this is fewer than three)

• Listing the correct diagnoses in the order of likelihood, withthe most likely diagnosis first

• Supporting diagnoses with pertinent findings obtained fromthe history and physical examination

The following are examples of actions that would result in lowerscores on the patient note:

• Using inexact, nonmedical terminology, such as pulledmuscle

• Listing improbable diagnoses with no supporting evidence

• Listing an appropriate diagnosis without listing supportingevidence

• Listing diagnoses without regard to the order of likelihood

Appendix B illustrates a blank patient note screen.

Appendix C provides examples of two completed patient notes.The samples also include annotations, highlighting actions thatwould add to or lower a patient note score.

A program for practicing typing the patient note is available onthe USMLE website (https://www.usmle.org/step-2-cs/).

STEP 2 CS SCORE REPORTING SCHEDULE

Step 2 CS examinees are grouped into testing periods accordingto the dates on which they test. The first results for a giventesting period will be issued on the first day of thecorresponding reporting period, and it is expected that resultsfor the vast majority of examinees who take the exam during thetesting period will be reported on this date. However, it isimportant to note that there will likely be a small number ofexaminees for whom scoring and quality assurance are notcompleted by the first day of the reporting period; these willtypically be examinees who took the exam in the latter part of thetesting period. Results for these examinees will be reported eachweek throughout the reporting period, and should be reportedno later than the last day of the score reporting period.

This schedule allows USMLE staff to enhance the qualityassurance and data collection/scoring procedures performedprior to score reporting. Additionally, it provides examinees, aswell as others who rely on Step 2 CS results, with guidelinesregarding when a result will be reported for a given exam date.These guidelines allow examinees to plan their exam registrationand scheduling in order to have their results in time to meetspecific deadlines, such as those related to graduation orparticipation in the National Resident Matching Program(NRMP), or "the Match." Information about testing periods andcorresponding reporting periods is available athttp://www.usmle.org/step-2-cs/#reporting.

RULES OF CONDUCT AND TESTING REGULATIONS

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You cannot discuss the cases with your fellow examinees,during breaks or at any time.

Conversation among examinees in languages other than Englishabout any subject is strictly prohibited at all times, includingduring breaks. Test center staff will be with you to monitoractivity. To maintain security and quality assurance, eachexamination room is equipped with video cameras andmicrophones to record every patient encounter.

The USMLE program retains the right to remove any examineefrom the examination who appears to represent a health orsafety risk to the standardized patients or staff of a clinical skillsevaluation center. This includes, but is not limited to, examineeswho appear ill, are persistently coughing or sneezing, have openskin lesions, or have evidence of active bleeding. Examinees whoare not feeling well are encouraged to seek medical advice priorto arrival at the center and, if consistent with medical advice,should consider rescheduling the date of their examination. Thiscan be done at the website of your registration entity.

Clinical skills evaluation center staff monitor all testingadministrations for the Step 2 CS examination. You must followinstructions of test center staff throughout the examination.Failure to do so may result in a determination of irregularbehavior. The USMLE Bulletin of Information provides acomplete description of irregular behavior and theconsequences of a finding of irregular behavior in the sectionstitled Testing Regulations and Rules of Conduct and IrregularBehavior. You must become familiar with the Bulletin ofInformation before you take your examination.

Irregular behavior includes any action by applicants, examinees,potential applicants, or others when solicited by an applicantand/or examinee that subverts or attempts to subvert theexamination process. Specific examples of irregular behaviorinclude, but are not limited to:

• Seeking, providing, and/or obtaining unauthorized access toexamination materials

• Providing false information or making false statements onor in connection with application forms, schedulingpermits, or other USMLE-related documents

• Taking or attempting to take an examination for which youare not eligible

• Taking an examination for someone or engaging someoneto take an examination for you

• Seeking, providing, or obtaining unauthorized assistanceduring the examination or attempting to do so

• Making notes of any kind while in the secure areas of thetest center, except on the writing materials provided at thetest center for this purpose

• Failing to adhere to any USMLE policy, procedure, or rule,including instructions of the test center staff

• Verbal or physical harassment of test center staff or otherexamination staff, or other disruptive or unprofessionalbehavior during the registration, scheduling, or examinationprocess

• Possessing any unauthorized materials, includingphotographic equipment, communication or recordingdevices, fitness and tracking monitors, and cell phones, inthe secure testing areas

• Altering or misrepresenting examination scores• Unauthorized reproduction by any means, including, but

not limited to, reconstruction through memorization,and/or dissemination of copyrighted examination materialsby any means, including the Internet

• Communicating or attempting to communicate aboutspecific test items, cases, and/or answers with anotherexaminee, potential examinee, or formal or informal testpreparation group at any time before, during, or after anexamination

• Failure to cooperate fully in any investigation of a violationof the USMLE rules

• Interacting with any standardized patient outside of thatstandardized patient's given case portrayal, before, during,or after the examination

• Conversing with other Step 2 CS examinees in any languageother than English at any time while at the test center

• Engaging in behaviors that could constitute a real orpotential threat to a patient’s safety, such as careless ordangerous actions during physical examination.

Instances of possible irregular behavior are thoroughlyinvestigated and actions may be taken under the USMLE policiesand procedures on irregular behavior.

COMMON ABBREVIATIONS FOR THE PATIENT NOTE

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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 beused 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.

APPENDIX A

Common Presenting Signs and Symptoms

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Please note that this list shows examples, and does not represent all possible presenting signs and symptoms that may beencountered during a Step 2 Clinical Skills examination.

Abdominal distensionAbdominal painAbnormal mensesAbnormal movementsAltered bowel habits

(e.g., constipation, diarrhea, fecal incontinence)Back painBloody stools/melenaBreast-related complaintsChest pain/discomfortChild and adolescent behavior concernsConfusionCoughDecreased sensation in extremitiesDental painDifficulty walkingDyspareuniaDysphagiaEar-related complaints

(e.g., pain, tinnitus, hearing loss)Easy bruisingEpistaxisEvaluation after a fallExtremity painEye complaints (e.g., pain, visual changes)FatigueFevers, chills and/or night sweatsFlank painGenital complaints (e.g., discharge, lesions, pain)HallucinationsHeadacheHematemesisHemoptysisHigh blood pressureHot flashesIndigestionInfant spitting up

Irritable infant/childJaundiceJaw painJoint painJoint swellingLeg swellingLoss of appetiteMass/lumpMemory lossMood disorderMouth and lip changesMuscle painNasal dischargeNausea/vomitingNeck painPalpitationsPost-operative complicationsPostpartum concerns/complicationsPregnancy-related concerns/complicationsPruritusRashSeizureSexual dysfunctionShortness of breathSinus pain/pressureSleep issuesSore throatSubstance useSyncopeTrouble concentratingUrinary complaints

(e.g., frequency, dysuria, retention, incontinence)Vertigo/dizziness/lightheadednessWeaknessWeight gainWeight lossWheezing

APPENDIX B

Patient Note Screen

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

APPENDIX C

Sample Patient Note Styles

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Various styles of writing patient notes for the Step 2 CS examination are acceptable. Two examples of patient notes are shown on thefollowing pages. These examples are not meant to represent ideal or perfect patient notes, nor should they be assumed to becomplete or accurate with respect to content. Both, however, would be considered acceptable. In addition, guidelines to helpexaminees 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)