Patient Note

Immediately after each encounter, you will have 10 minutes to complete a patient note. A patient note is the medical record you would compose after seeing a patient in a clinic, office or emergency department. Approach the note as if you are communicating with another health pro-fessional.The patient note is the communication media between health professionals.

Blank paper will be provided for note taking in the examination room, but all sheets must be returned with your completed patient notes. The sheets of blank paper are numbered.

You should record pertinent medical history and physical examination findings, as well as your initial differential diagnoses. Finally, you will list the diagnostic studies you would order next on that particular patient.

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