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Old 02-12-2012
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Steps History: 1 + CK
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Unhappy messed up patient note

I had taken sc recently. I can not stop thinking about it.

In a patient note i wrote patient had trauma. And my differential was all about that. But infact (i could not understand patient's response to the q 'What brought you today?' I do not know how, i thought he had trauma to the leg. And even more in the closure i said 'You had trauma to your leg...bla bla bla..Would you like to add anything else?' He did not correct me.

Now i am thinking and realized that the patient did not say anything about trauma, but -still i don't know how- i accepted it as a trauma related.

And of course, in my patient note writes trauma, and it affects all the dx and work up. But real senario there is no.

Does this case affect all my exam? Will it be considered as lying

But but but, i said him you had trauma...and he said nothing....

What do you think? IT was not intentional...
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