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Can I lie in the patient note?

9174 Views 9 Replies 7 Participants Last post by  nikhilesh, 
I
Ok suppose I had a case of infectious mononucleosis and I forgot to ask about and examine the abdomen or I forgot to ask about fatigue ...
Can I then write in the patient note that abdomen is soft, no tenderness and in the history I write no fatigue.

I mean is that dangerous, will they match the PN with what the patient said in the encounter?

Please help
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Sabio
Don't make up the PN

Don't do it. That cud cost you the whole exam.
If you forgot to examine the abdomen in a case of probable infectious mononucleosis then your best bet is to mention it in the differential and do not make up for that in the history or physical notes.
Because say if you wrote abdomen is soft, non tender, BS present, hepatosplenomegaly, no CVA tenderness. Then in fact the patient was trained to demonstrate tenderness in left upper quadrant upon palpation. Then in that case you made a fatal mistake by saying there's no tenderness. Furthermore, this will serve as eye opener as they may likely check with the SP if he had forgotten to show the tenderness and then they'll find out that you didn't even examine the abdomen and in this case they will for sure fail you the whole exam.

Bottom line, Don't ever make up information in the PN, write only what you have asked about and done only.
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A
:cool:
Evgeniy said:
Ok suppose I had a case of infectious mononucleosis and I forgot to ask about and examine the abdomen or I forgot to ask about fatigue ...
Can I then write in the patient note that abdomen is soft, no tenderness and in the history I write no fatigue.

I mean is that dangerous, will they match the PN with what the patient said in the encounter?

Please help
Click to expand...
hi i have a thing there.... sabio is little too emotional with word lying i guess(most of us are)
better avoid making up things but little things are okay, happens to every one , one might forget something inside but patient note has to be complete too, definitely do not concoct any stories but in order to make the whole thing complete , some alterations would not hurt, USMLE wants to know what you know and what is required, not what you forgot or for worse how you make up stories...
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accurate said:
:cool:
hi i have a thing there.... sabio is little too emotional with word lying i guess(most of us are)
better avoid making up things but little things are okay, happens to every one , one might forget something inside but patient note has to be complete too, definitely do not concoct any stories but in order to make the whole thing complete , some alterations would not hurt, USMLE wants to know what you know and what is required, not what you forgot or for worse how you make up stories...
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So now I have conflicting opinions
Should I do it or not :confused:
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Sabio
Evgeniy said:
So now I have conflicting opinions
Should I do it or not :confused:
Click to expand...
I disagree with accurate.
No matter how minor the point that you make up, it may in fact prove to be a grave mistake.
Suppose you write (allergies: NKDA) and you did not ask about it. if the patient had no allergies then of course nothing will happen but if in fact the patient had allergies and you are saying no allergies and they'll likely think that you made up that line and this might "I think" affect the whole scoring process as the physician rater will be now more skeptical of your PNs.
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Sabio said:
I disagree with accurate.
No matter how minor the point that you make up, it may in fact prove to be a grave mistake.
Suppose you write (allergies: NKDA) and you did not ask about it. if the patient had no allergies then of course nothing will happen but if in fact the patient had allergies and you are saying no allergies and they'll likely think that you made up that line and this might "I think" affect the whole scoring process as the physician rater will be now more skeptical of your PNs.
Click to expand...
so a bad encounter means a worse PN, A GOOD CHANCE TO FAIL IN BOTH....
misinterpretation of my response....
I was very emphatic when i said dont make up stories.....that is i said dont say things that might go against you, but minor things which can be readily added are clear cut negative history and a expected normal physical exam(one you do along with the focused)just a lilttle trick for scoring well on PN
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csevideo
patient note

Do not under any circumstances lie. make sure you are in a steady frame of mind and conduct the appropriate exams while you are with the patient. you need to thoroughly prepare for the exam so that you dont forget to check the pts. abdomen.

there is a high likelyhood that you could fail the exam if you lie.

if you forget to check a system, then you forgot.

fill in the space with what you did check.

the patient note should not be overwhelming for the physician who is scoring your report. so if there is not a "whole lot" of physical exam information, dont worry just be as precise as you can. but the most important thing is to get the timing of your physical exam experience down to at the most 61/2 min that includes closure. It can be done.

If you practice and study and you are cool headed and prepared you will not need to find an alternative to documenting what you forget in your physical exam :)

good luck
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K
totally agree with sabio and csevideo
my friend lied few simple lies in PN and she failed
I don't know if that was the reason for her failure but it was certainly a factor
Kaplan teachers told her OK to write things that she did not do :confused:
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A
Just write down the things as they happen. If you forget a point in the history taking just neglect it. The SP is well trained to document (on his PC) every question you will ask, he will have a long list to check if you asked this and this or not. Missing 1 or 2 points is not that serieous issue, especially that this exam tests many other features of the applicant and I strongly think that honesty is one of them.:cool:
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N
I am with Sabio.... and further more I think all the cases are video recorded and taped... so they check your language, interrogation skills and of course the PN... if they find any discrepancy in these... it mean u are making things up....
the point of the exam is to see how well can you handle patients and interrogate them... if you didn't ask something then how can you write about it?
2 of my friends took and passed the CS and they told me they were video recorded...
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