Step 2 CS Patient Note

Step 2 of the United States Medical Licensing Examination (USMLE) assesses the ability of medical students to apply medical knowledge, skills, and understanding of clinical science essential for patient care with an emphasis on health promotion and disease prevention.

The USMLE Step 2 Clinical Skills (CS) exam consists of a series of learner-patient encounters in which the medical students are expected to:

  • investigate the simulated patient's chief complaint,

  • obtain a thorough assessment of their medical history (medications, allergies, social history) and family history,

  • then complete a physical examination,

  • determine differential diagnoses,

  • then write a patient note based on their findings.

LearningSpace offers a pre-structured section called Step 2 CS Patient Note to facilitate such an assessment. 
It is available at the bottom of the New Item list when creating a Post-Encounter Learner checklist. Clicking it inserts a fully prepared individual section into the checklist, consisting of items best suited for Step 2 CS assessment.

Due to its purpose, this item type is only available for the Post-Encounter Learner part.

You can modify the textual parts by clicking the desired field. For more information, see the Text and Structured text pages.

As the Step 2 CS assessment requires learners to phrase their responses, the system cannot calculate point values. Scoring of responses necessitates the active participation of an evaluator: scores are determined by a professionally competent Faculty member. Such an evaluation is referred to in LearningSpace as Open-Ended Question Scoring (OEQS).

IMPORTANT: As with all other item types, Step 2 CS Patient Note is NOT scored by default. If the default setting is not changed, answers will not be displayed for OEQS.

Based on user practice, it is recommended that the last item be set scored (by questionnaire), meaning that a Special Section part is created with the necessary questions along which the Step 2 CS section can be scored, then that Section is selected from the drop-down prompted when setting the scoring to Questionnaire.

The Special Section used for scoring does not necessarily have to be created within the same Case.

IMPORTANT: During OEQS grading, answers entered for a Step 2 CS Patient Note item will be displayed on one page for the faculty submitting the grading.
However, if the items are separately added, that is, not as one pre-compiled section of Step 2 CS Patient Note. Still, as a series of Text items (for History and Physical Examination) and Structured Text items (for Data Interpretation), the answers for the items will be separately displayed for grading - one item per page.

For further information, visit our Case Manager and Cases - How to pages or watch our Case Manager Training Videos.