2010

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

Copyright 2003-2009 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 Case Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Standardized PatientBased Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Examination Blueprint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Description of the Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Examination Length . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Equipment and Examinee Instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
The Patient Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Telephone Patient Encounters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
The Patient Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Other Case Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Testing Regulations and Rules of Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Irregular Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Scoring the Step 2 CS Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Scoring of the Step 2 Clinical Skills Subcomponents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2009 Step 2 CS Score Report Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Terms Used in the Step 2 CS Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Common Abbreviations for the Patient Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Appendix A: Patient Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Appendix B: Patient Note Screen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Appendix C: Sample Patient Note Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Appendix D: Clinical Skills Evaluation Center Addresses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

INTRODUCTION

clinical knowledge. Step 2 CS uses standardized

patients to test medical students and graduates on
their ability to gather information from patients, perform physical examinations, and communicate their
findings to patients and colleagues.

The United States Medical Licensing Examination

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

This document is intended to help examinees prepare

for the Step 2 CS component of the USMLE. Persons
preparing to take the Step 2 CS examination should
also view the video available at the USMLE website
(www.usmle.org).

Results of the USMLE are reported to medical licensing authorities in the United States and its territories
for use in granting the initial license to practice medicine. The USMLE is sponsored by the Federation of
State Medical Boards (FSMB) and the National Board
of Medical Examiners (NBME).

Information on eligibility, registration, and scheduling

is available in the USMLE Bulletin of Information,
which is posted on the USMLE website. Students and
graduates of international medical schools must also
consult the ECFMG Information Booklet and the
ECFMG website (www.ecfmg.org).

Step 2 of the USMLE assesses the ability of examinees to apply medical knowledge, skills, and understanding of clinical science essential for the provision
of patient care under supervision, and includes
emphasis on health promotion and disease prevention.
Step 2 ensures that due attention is devoted to the
principles of clinical sciences and basic patientcentered skills that provide the foundation for the safe
and effective practice of medicine.

The information in this document, as well as other

materials, is available at the USMLE website and also
via CD from your registration entity. Changes in the
USMLE program may occur after the release of this
document. If changes occur, information will be
posted on the USMLE website. You must obtain the
most recent information to ensure an accurate
understanding of current USMLE policy.

There are two components of Step 2, Clinical

Knowledge (CK) and Clinical Skills (CS). Step 2 CK
uses the multiple-choice examination format to test

STEP 2 CS CASE DEVELOPMENT

Standardized PatientBased Examinations

nees. On any examination day, the set of cases will

differ from the combination presented the day before
or the following day, but each set of cases has a comparable degree of difficulty.

The patients you will see are people trained to portray

a clinical problem. This method of assessment is
referred to as a standardized patient examination.
Most medical school programs in the United States
and Canada accredited by the Liaison Committee on
Medical Education (LCME) use standardized patients
for instruction; many of these institutions use standardized patients for evaluation as well.

The intent is to ensure that examinees encounter a

broad spectrum of cases reflecting common and
important symptoms and diagnoses. The criteria used
to define the blueprint and create individual examinations focus primarily on presenting complaints and
conditions.

Standardized patients have been used since 1998 in

the ECFMG Certification process, and have also been
incorporated into the Medical Council of Canada's
medical licensure examination for Canadian and international medical graduates. The standardized
patientbased testing method was established more
than 35 years ago, and its procedures have been tested
and validated in the United States and internationally.

Presentation categories include, but are not limited to,

cardiovascular, constitutional, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric,
respiratory, and women's health. Examinees will see
cases from some, but not all, of these categories. The
selection of cases is also guided by specifications
relating to acuity, age, gender, and type of physical
findings presented in each case.

Examination Blueprint

Your Step 2 CS administration will include twelve

patient encounters. These include a very small number
of nonscored patient encounters, which are added for
pilot testing new cases and other research purposes.
Such cases are not counted in determining your score.

As part of the test development process, practicing

physicians and medical educators develop and review
cases to ensure that they are accurate and appropriate.
These cases represent the kinds of patients and problems normally encountered during medical practice in
the United States. Most cases are specifically
designed to elicit a process of history taking and
physical examination that demonstrates the examinee's ability to list and pursue various plausible
diagnoses.

When you take the Step 2 CS examination, you will

have the same opportunity as all other examinees to
demonstrate your clinical skills proficiency. The
examination is standardized, so that all examinees
receive the same information when they ask standardized patients the same or similar questions. An ongoing mechanism of quality control is employed to
ensure that the examination is fair to all. The quality
control approach focuses on consistency in portrayal
and scoring of the individual cases, and utilizes both
observation of live encounters and review of digital
recordings.

The cases that make up each administration of the

Step 2 CS examination are based upon an examination blueprint. An examination blueprint defines the
requirements for each examination, regardless of
where and when it is administered. The sample of
cases selected for each examination reflects a balance
of cases that is fair and equitable across all exami-

DESCRIPTION OF THE EXAMINATION

Wear comfortable, professional clothing and a white

laboratory or clinic coat. The proctors will cover with
adhesive tape anything on the laboratory coat that
identifies either you or your institution.

When you arrive at the test center on the day of your

examination, bring the Scheduling Permit you
received when your registration was completed, your
Confirmation Notice, and an unexpired, governmentissued form of identification that includes a photograph and signature, such as a current driver's license
or passport. Your name as it appears on your
Scheduling Permit must match the name on your
form(s) of identification exactly. The only acceptable
differences are variations in capitalization; the presence of a middle name, middle initial, or suffix on
one document and its absence on the other; or the
presence of a middle name on one and middle initial
on the other.

The only piece of medical equipment you may bring

is an unenhanced standard stethoscope, which is subject to inspection by test center staff. All other necessary medical equipment 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 bring a laboratory coat
or stethoscope, a limited number of coats and stethoscopes are available at each test center. However, it is
strongly recommended you bring your own.

If you do not bring acceptable identification, you

will not be admitted to the test. In that event, you
must pay a fee to reschedule your test. Your rescheduled test date(s) must fall within your assigned eligibility period.

As more fully explained in the Bulletin of Information,

unauthorized possession of personal items while you are
in the secure areas of the test center is prohibited, and
unauthorized items will be taken away. However, in certain limited circumstances, exceptions to this policy
may be made for medical reasons, provided that permission is granted in advance of test administration. If you
believe that you have a medical condition that requires
you to use medication, an external appliance, or electronic device in the secure areas of the test center, you
will need to submit a written request. Information on
how to submit a request is available in the USMLE
Bulletin of Information. Examples of appliances and
devices to which this policy applies include non-standard stethoscopes, (eg, electronic or digitally amplified
or otherwise enhanced non-standard stethoscopes),
insulin pumps, inhalers, syringes, medications (oral,
inhaled, injectable), TENS units, breast pumps, hearing
aids, wheelchairs, canes, crutches, and casts.

The time you should arrive at the test center is listed

in the Confirmation Notice you will print after scheduling your appointment.
Please note that, as part of the Step 2 CS registration
process, you acknowledge and agree to abide by
USMLE policies and procedures, including those
related to confidentiality.
Please bring only necessary personal items with you to
the center. You may not possess cellular telephones,
watches of any type, pagers, personal digital assistants
(PDAs), two-way communication devices, or notes or
study materials of any kind at any time during the
examination, including during breaks. These items
must be stored during the examination.

Each examination session begins with an on-site orientation. If you arrive during the on-site orientation, you may be allowed to test; however, you will
be required to sign a Late Admission Form. If you
arrive after the on-site orientation, you will not be
allowed to test. You will have to reschedule your
testing appointment and will be required to pay the
rescheduling fee.

Each test center contains a locked storage area with

small open cubicles. Coat racks are also available.
Each examinee is assigned one of the cubicles in
which all personal items must be stored during the
examination. Examinees are not permitted access to
the cubicles at any time during the examination,
including breaks. Luggage may not be stored in the
center. There are no waiting facilities for spouses,
family, or friends; plan to meet them elsewhere after
the examination.

The clinical skills evaluation centers are secured facilities. Once you enter the secured area of the center for
orientation, you may not leave that area until the
examination is complete.
5

repeat them unless you believe the case specifically

requires it. For instance, you may encounter patient
problems or conditions that suggest the need to confirm or re-check the recorded vital signs and/or perform specific maneuvers in measuring the vital signs.
However, if you do repeat the vital signs, with or
without additional maneuvers, you should consider
the vital signs that were originally listed as accurate
when developing your differential diagnosis and
work-up plan.

Throughout the examination day, staff members,

wearing identifying 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 twelve
patient encounters. The examination session lasts
approximately 8 hours, and two breaks are provided.
The first break is 30 minutes long; the second break is
15 minutes long. You may use the restrooms before the
exam and during breaks. A light meal will be served
during the first break. The test center is unable to
accommodate special meal requests. However, you
may bring your own food, provided that no refrigeration or preparation is required. Smoking is prohibited
throughout the center.

You may encounter a case in which the examinee

instructions include the results of a lab test. In this
type of patient encounter the patient is returning for a
follow-up appointment after undergoing testing.
The Patient Encounter
When you enter the room, you will usually encounter
a standardized patient. By asking this patient relevant
questions and performing a focused physical examination, you will be able to gather enough information to
develop a preliminary differential diagnosis and a
diagnostic work-up plan.

Equipment and Examinee Instructions

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

You will be expected to communicate with the standardized patients in a professional and empathetic
manner. As you would when encountering real
patients, you should answer any questions they may
have, tell them what diagnoses you are considering,
and advise them on what tests and studies you will
order to clarify their diagnoses.

There is a one-way observation window in each

examination room. These are used for quality assurance, training, and research.

The elements of medical history you need to obtain in

each case will be determined by the nature of the
patient's problems. Not every part of the history needs to
be taken for every patient. Some patients may have acute
problems, while others may have more chronic ones.

Before the first patient encounter, you will be provided with a clipboard, blank paper for taking notes, and
a pen. There will be an announcement at the beginning of each patient encounter. When you hear the
announcement you may review the patient information posted on the examination room door (examinee
instructions). You may also make notes at this time.
DO NOT write on the paper before the announcement
that the patient encounter has begun.

You will not have time to do a complete physical

examination on every patient, nor will it be necessary
to do so. Pursue the relevant parts of the examination,
based on the patient's problems and other information
you obtain during the history taking.
The cases are developed to present in a manner that
simulates how patients present in real clinical settings.
Therefore, most cases are designed realistically to
present more than one diagnostic possibility. Based on
the patient's presenting complaint and the additional
information you obtain as you begin taking the
history, you should consider all possible diagnoses
and explore the relevant ones as time permits.

The examinee instruction sheet gives you specific

instructions and indicates the patient's name, age, gender, and reason for visiting the doctor. It also indicates
his or her vital signs, including heart rate, blood pressure, temperature (Celsius and Fahrenheit), and respiratory rate, unless instructions indicate otherwise. You
can accept the vital signs on the examinee instruction
sheet as accurate, and do not necessarily need to
6

Another exception is that you should not swab the

standardized patients throat for a throat culture. If
you believe that this diagnostic/laboratory test is indicated, include it on your proposed diagnostic workup.

If you are unsuccessful at Step 2 CS and must, therefore, repeat the examination, it is possible that during
your repeat examination you will see similarities to
cases or patients that you encountered on your prior
attempt. Do not assume that the underlying problems
are the same or that the encounter will unfold in
exactly the same way. It is best if you approach each
encounter, whether it seems familiar or not, with an
open mind, responding appropriately to the information provided, the history gathered, and the results of
the physical examination.

Excluding the restricted physical examination maneuvers, you should assume that you have consent to do a
physical examination on all standardized patients,
unless you are explicitly told not to do so as part of
the examinee instructions for that case.
Announcements will tell you when to begin the patient
encounter, when there are 5 minutes remaining, and
when the patient encounter is over. In some cases you
may complete the patient encounter in fewer than 15
minutes. If so, you may leave the examination room
early, but you are not permitted to re-enter. Be certain
that you have obtained all necessary information
before leaving the examination room. Re-entering an
examination room after leaving will be considered
misconduct.

Physical Examination
You should perform physical examination maneuvers
correctly and expect that there will be positive physical findings in some instances. Some may be simulated, but you should accept them as real and factor them
into your evolving differential diagnoses.
You should attend to appropriate hygiene and to
patient comfort and modesty, as you would in the care
of real patients. Female patients will be wearing bras,
which you may ask them to loosen or move if necessary for a proper examination.

Telephone Patient Encounters

Telephone patient encounters begin like all encounters; you will read a doorway instruction sheet that
provides specific information about the patient. As
with all patient encounters, as soon as you hear the
announcement that the encounter has begun, you may
make notes about the case before entering the examination room.

With real patients in a normal clinical setting, it is

possible to obtain meaningful information during your
physical examination without being unnecessarily
forceful in palpating, percussing, or carrying out other
maneuvers that involve touching. Your approach to
examining standardized patients should be no different. Standardized patients are subjected to repeated
physical examinations during the Step 2 CS exam; it
is critical that you apply no more than the amount
of pressure that is appropriate during maneuvers
such as abdominal examination, examination of the
gall bladder and liver, eliciting CVA tenderness,
examination of the ears with an otoscope, and examination of the throat with a tongue depressor.

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

the telephone.

You should interact with the standardized patients as

you would with any patients you may see with similar
problems. The only exception is that certain parts of
the physical examination MUST NOT BE DONE:
rectal, pelvic, genitourinary, inguinal hernia, female
breast, or corneal reflex examinations. If you believe
one or more of these examinations are indicated, you
should include them in your proposed diagnostic
work-up. All other examination maneuvers are completely acceptable, including femoral pulse exam,
inguinal node exam, back exam, and axillary exam.

Do not dial any numbers.

Push the speaker button above the yellow dot on
the phone to be connected to the patient
caregiver or patient.
You will be permitted to make only one
phone call.
Do not touch any buttons on the phone until
you are ready to end the call touching any
buttons may disconnect you.
To end the call on a phone case, press the
speaker button above the yellow dot.
You will not be allowed to call back after you
end the call.

All examinees should be prepared for the possibility

that they may have to write one or more patient notes
by hand.

Obviously, physical examination of the patient is not

possible for telephone encounters, and will not be
required. However, for these cases, as for all others,
you will have relevant information and instructions
and will be able to take a history and ask questions.
As with other cases, you will write a patient note after
the encounter. Because no physical examination is
possible for telephone cases, leave that section of the
patient note blank.

Patient notes are rated by physicians who are well

trained at reading notes and can interpret most handwriting. However, extreme illegibility will be a problem and can adversely impact a score. Everyone who
writes patient notes by hand should make them as legible as possible.

The Patient Note

If you have a case for which you think no diagnostic

workup is necessary, write "No studies indicated"
rather than leaving that section blank.

Immediately after each patient encounter, you will

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

You will not receive credit for listing examination

procedures you WOULD have done or questions you
WOULD have asked had the encounter been longer.
Write ONLY the information you elicited from the
patient through either physical examination or history
taking.

You should record pertinent medical history and physical examination findings obtained during the
encounter, as well as your initial differential diagnoses. Finally, you will list the diagnostic studies you
would order next for that particular patient. If you
think a rectal, pelvic, inguinal hernia, genitourinary,
female breast, or corneal reflex examination, or a
throat swab, would have been indicated in the
encounter, list it as part of your diagnostic workup.
Treatment, consultations, or referrals should not
be included in your work-up plan.

When you hear the announcement to stop writing, put

down your pen immediately or click "Submit" on the
computer. Continuing to write after the announcement
to stop will be considered misconduct. Remain seated
until all examinees patient notes have been collected.
Other Case Formats
The kinds of medical problems that your patients will
portray are those you would commonly encounter in a
clinic, doctor's office, emergency department, or hospital setting. Although there are no young children
presenting as patients, there may be cases in which
you encountereither in the examination room or via
the telephonea parent or caregiver of a child.

Appendix A illustrates a blank patient note page similar to what you will be asked to complete if you write
the note by hand. Appendix B illustrates a blank
patient note screen similar to what would appear to
examinees who choose to type their notes. Appendix
C provides sample patient note styles. A program for
practicing typing the patient note is available on the
USMLE website (www.usmle.org).

In some instances you may be instructed to perform a

physical examination that relates to a specific medical
condition, life circumstance, or occupation. Synthetic
models, mannequins, or simulators provide an appropriate format for assessment of sensitive examination
skills such as genital or rectal examination, and may
be used for these cases. In such cases, specific
instructions regarding the use of these devices will be
provided. If you encounter any case for which you
decide no physical examination is necessary, leave
that section of the patient note blank.

Typically you will be able to choose, for each patient

encounter, whether to write the patient note by hand or
type it on a computer. Occasionally, due to technical or
administration problems, the option of typing the
patient note may not be available for one or more
patient encounters. When this happens, examinees will
be required to write their patient notes by hand.

TESTING REGULATIONS AND RULES OF CONDUCT

You cannot discuss the cases with your fellow

examinees, during breaks or at any time.
Conversation among examinees in languages other
than English about any subject is strictly prohibited at
all times, including during breaks. Test center staff
will be with you to monitor activity. To maintain
security and quality assurance, each examination
room is equipped with video cameras and microphones to record every patient encounter.

!
!
!
!

The USMLE program retains the right to remove any

examinee from the examination who appears to represent a health or safety risk to the standardized patients
or staff of a clinical skills evaluation center. This
includes, but is not limited to, examinees who appear
ill, are persistently coughing or sneezing, have open
skin lesions, or have evidence of active bleeding.
Examinees who are not feeling well are encouraged to
seek medical advice prior to arrival at the center and,
if consistent with medical advice, should consider
rescheduling the date of their examination. This can
be done at the website of your registration entity.

!
!
!

Clinical skills evaluation center staff monitor all testing

administrations for the Step 2 CS examination. You
must follow instructions of test center staff throughout
the examination. Failure to do so may result in a determination of irregular behavior. The USMLE Bulletin of
Information provides a complete description of irregular
behavior and the consequences of a finding of irregular
behavior. You must become familiar with the Bulletin of
Information before you take your examination.

!
!

Irregular behavior includes any action by applicants,

examinees, potential applicants, or others when
solicited by an applicant and/or examinee that subverts or attempts to subvert the examination process.
Specific examples of irregular behavior include, but
are not limited to:
!
!
!
!

Seeking and/or obtaining unauthorized access to

examination materials;
Providing false information or making false
statements on application forms or other
USMLE-related documents;
Taking an examination without being eligible for
it or attempting to do so;
Impersonating an examinee or engaging
someone else to take the examination for you;

Giving, receiving, or obtaining unauthorized

assistance during the examination or attempting
to do so;
Making notes of any kind during the
examination, except on the blank paper
provided to you;
Failure to adhere to any USMLE policy,
procedure or rule, including instructions of
the test center staff;
Disruptive or unprofessional behavior at the
test center;
Interacting with any standardized patient outside
of that standardized patient's given case portrayal,
before, during, or after the examination;
Conversing with other Step 2 CS examinees in
any language other than English at any time
while at the test center;
Possessing unauthorized materials, including
notes and study guides, photographic equipment,
communication or recording devices, pagers,
cellular phones, watches of any type, and
personal digital assistants (PDAs) during any
part of the testing session, including during
breaks;
Altering or misrepresenting examination scores;
Any unauthorized reproduction by any means,
including reconstruction through memorization
and/or dissemination of copyrighted examination
materials and examination content (this includes
the reproduction and dissemination of
examination content on the Internet, email,
and listservs);
Providing or attempting to provide any
information, including that relating to
examination content, that may give or attempt
to give unfair advantage to individuals who
may be taking the examination;
Engaging in behaviors that could constitute a
real or potential threat to a patients safety, such
as careless or dangerous actions during physical
examination.

Instances of possible irregular behavior are thoroughly investigated and actions may be taken under the
USMLE policies and procedures on irregular behavior. Please refer to the appropriate USMLE Bulletin of
Information for Rules of Conduct and Irregular
Behavior.
9

SCORING THE STEP 2 CS EXAMINATION

The ICE subcomponent includes assessment of:

Step 2 CS is designed to evaluate your ability to gather information that is important for a given patient
presentation. During your physical examination of the
standardized patient, you should attempt to elicit
important positive and negative signs. Make sure you
discuss with the patient your initial diagnostic impression and work-up plan. The patients may ask questions concerning their complaints. You should address
each patient's concern as you would in a normal clinical setting.

Data gathering patient information collected

by history taking and physical examination
Documentation completion of a patient note
summarizing the findings of the patient
encounter, diagnostic impression, and initial
patient work-up

Data gathering is scored by checklists completed by

the standardized patients. The checklists are developed by committees of clinicians and medical school
clinical faculty and comprise the essential history and
physical examination elements for specific clinical
encounters. The patient note is scored by trained
physician raters. Copies of the patient note template,
sample patient note styles, and software to practice
typing the note are available on the USMLE website.
(See also Appendices A C.)

The ability to communicate effectively with patients,

demonstrating appropriate interpersonal skills, is
essential to safe and effective patient care. Step 2 CS
is intended to determine whether physicians seeking
an initial license to practice medicine in the United
States, regardless of country of origin, can communicate effectively with patients. Carefully developed rating scales, as well as intensive training in their use,
are used by the standardized patients to assess communication, interpersonal skills, and English-speaking
skills.

The CIS subcomponent includes assessment of:

Your ability to document in the patient note the findings from the patient encounter, diagnostic impression, and initial patient work-up will be rated by
physician raters. You will be rated based upon the
quality of documentation of important positive and
negative findings from the history and physical examination, as well as your listed differential diagnoses
and diagnostic assessment plans. As is the case with
other aspects of Step 2 CS scoring, physician raters
receive intensive training and monitoring to ensure
consistency and fairness in rating.

Scoring of the Step 2 Clinical Skills

Subcomponents
USMLE Step 2 CS is a pass/fail examination.
Examinees are scored in three separate subcomponents: Integrated Clinical Encounter (ICE),
Communication and Interpersonal Skills (CIS), and
Spoken English Proficiency (SEP). Each of the three
subcomponents must be passed in a single administration in order to achieve a passing performance on
Step 2 CS.

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Questioning skills examples include:

use of
- open-ended questions, transitional
statements, facilitating remarks
avoidance of
- leading or multiple questions, repeat
questions unless for clarification,
medical terms/jargon unless
immediately defined, interruptions
when the patient is talking
accurately summarizing information from
the patient
Information-sharing skills examples include:
acknowledging patient issues/concerns and
clearly responding with information
avoidance of medical terms/jargon unless
immediately defined
clearly providing
- counseling when appropriate
- closure, including statements about
what happens next
Professional manner and rapport examples
include:
asking about
- expectations, feelings, and concerns
of the patient

Step 2 CS Score Report Schedule

- support systems and impact of illness,

with attempts to explore these areas
showing
- consideration for patient comfort
during the physical examination
- attention to cleanliness through hand
washing or use of gloves
providing opportunity for the patient to
express feelings/concerns
encouraging additional questions or
discussion
making
- empathetic remarks concerning
patient issues/concerns
- patient feel comfortable and respected
during the encounter

Step 2 CS examinees are grouped into testing periods

according to the dates on which they test. The first
results for a given testing period will be issued on the
first day of the corresponding reporting period, and it
is expected that results for the vast majority of examinees who take the exam during the testing period will
be reported on this date. However, it is important to
note that there will likely be a small number of examinees for whom scoring and quality assurance are not
completed by the first day of the reporting period;
these will typically be examinees who took the exam
in the latter part of the testing period. Results for
these examinees will be reported each week throughout the reporting period, and should be reported no
later than the last day of the score reporting period.

CIS performance is assessed by the standardized

patients, who provide a global rating of these skills
using a series of generic rating scales. The domains
included in these scales are, in part, based upon the
scales used in the former Clinical Skills Assessment
(CSA) of the Educational Commission for Foreign
Medical Graduates, with enhancements based upon
national consensus statements on essential communication skills and upon review of other commonly used
rating forms.

This schedule allows USMLE staff to enhance the

quality assurance and data collection/scoring procedures performed prior to score reporting. Additionally,
it provides examinees, as well as others who rely on
Step 2 CS results, with guidelines regarding when a
result will be reported for a given exam date. These
guidelines allow examinees to plan their exam registration and scheduling in order to have their results in
time to meet specific deadlines, such as those related
to graduation or participation in the National Resident
Matching Program (NRMP), or "the Match."
Information about testing periods and corresponding
reporting periods is available at
http://www.usmle.org/Examinations/step2/step2cs_rep
orting.html.

The SEP subcomponent includes assessment of:

Clarity of spoken English communication within

the context of the doctor-patient encounter
(eg, pronunciation, word choice, and minimizing
the need to repeat questions or statements)

SEP performance is assessed by the standardized

patients using rating scales and is based upon the frequency of pronunciation or word choice errors that
affect comprehension, and the amount of listener
effort required to understand the examinee's questions
and responses.

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TERMS USED IN THE STEP 2 CS EXAMINATION

Lists similar to the one below will be available on-site for reference during Step 2 CS administrations.
UNITS OF MEASURE
kg
g
mcg
mg
lbs
oz
m
cm
min
hr
C
F

kilogram
gram
microgram
milligram
pounds
ounces
meter
centimeter
minute
hour
Celsius
Fahrenheit

VITAL SIGNS
BP
HR
R
T

blood pressure
heart rate
respirations
temperature

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COMMON ABBREVIATIONS FOR THE PATIENT NOTE

Note: This is not intended to be a complete list of acceptable abbreviations, but rather represents the types of common abbreviations that may be used 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.
yo
m
f
b
w
L
R
hx
h/o
c/o

+
-

year-old
male
female
black
white
left
right
history
history of
complaining of
without or no
positive
negative

Abd
AIDS
AP
BUN
CABG
CBC
CCU
CHF
cig
COPD
CPR
CT
CVA
CVP
CXR
DM
DTR
ECG
ED
EMT
ENT
EOM
ETOH

abdomen
acquired immune deficiency syndrome
anteroposterior
blood urea nitrogen
coronary artery bypass grafting
complete blood count
cardiac care unit
congestive heart failure
cigarettes
chronic obstructive pulmonary disease
cardiopulmonary resuscitation
computed tomography
cerebrovascular accident
central venous pressure
chest x-ray
diabetes mellitus
deep tendon reflexes
electrocardiogram
emergency department
emergency medical technician
ears, nose, and throat
extraocular muscles
alcohol

Ext
FH
GI
GU
HEENT
HIV
HTN
IM
IV
JVD
KUB
LMP
LP
MI
MRI
MVA
Neuro
NIDDM
NKA
NKDA
NL
NSR
P
PA
PERLA
po
PT
PTT
RBC
SH
TIA
U/A
URI
WBC
WNL

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extremities
family history
gastrointestinal
genitourinary
head, eyes, ears, nose, and throat
human immunodeficiency virus
hypertension
intramuscularly
intravenously
jugular venous distention
kidney, ureter, and bladder
last menstrual period
lumbar puncture
myocardial infarction
magnetic resonance imaging
motor vehicle accident
neurologic
non-insulin-dependent diabetes mellitus
no known allergies
no known drug allergy
normal/normal limits
normal sinus rhythm
pulse/heart rate
posteroanterior
pupils equal, react to light
and accommodation
orally
prothrombin time
partial thromboplastin time
red blood cells
social history
transient ischemic attack
urinalysis
upper respiratory tract infection
white blood cells
within normal limits

APPENDIX A
Patient Note
If you write the patient note by hand, you will fill out a form similar to this after each patient encounter.

HISTORY: Include significant positives and negatives from history of present illness, past medical history,
review of system(s), social history, and family history.

PHYSICAL EXAMINATION: Indicate only pertinent positive and negative findings related to the patient's chief
complaint.

DIFFERENTIAL DIAGNOSES: In order of likelihood

(with 1 being the most likely), list up to 5 potential or
possible diagnoses for this patient's presentation
(in many cases, fewer than 5 diagnoses are likely):

DIAGNOSTIC WORKUP: List immediate plans

(up to 5) for further diagnostic workup:

1.
2.
3.
4.
5.

1.
2.
3.
4.
5.

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APPENDIX B
Patient Note Screen
If you type the patient note, you will use a program similar to the one pictured below. You can practice using the
patient note software by using the program provided on the USMLE Orientation Materials CD and at the USMLE
website (www.usmle.org). The patient note screen that appears during the actual examination will have a status bar
for each field, indicating how much space remains.

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APPENDIX C
Sample Patient Note Styles
Patient Note Example Two

Various styles of writing patient notes for the Step 2

CS examination are acceptable. Two examples of
handwritten patient notes are shown on the following
pages; these demonstrate some of the acceptable variations in style. These examples are not meant to represent ideal or perfect patient notes, nor should they
be assumed to be complete or accurate with respect to
content. Both formats and styles, however, would be
considered acceptable.

Patient Note Example Two is written in a telegraphic

or bullet style. There are no complete sentences,
although there are some complete phrases. In some
parts of the History section, in particular, one or two
words stand alone. The writer of this note has chosen
to transcribe the patient's blood pressure from the
examinee instruction sheet. You may wish to include
vital signs if they are particularly relevant to the case.

Patient Note Example One

In this note only four items are listed in both the

Differential Diagnosis and in the Diagnostic Workup
sections; again, this is acceptable. This sample also
contains some abbreviations or symbols not included
in the list of common abbreviations posted at each
writing station, but, as in Example One, they are generally recognizable. This note is printed throughout,
although a mixture of cursive script and printing is
also acceptable, provided both are legible.

Patient Note Example One is written primarily in a

narrative style. The History section is written in complete or nearly complete sentences, and the Physical
Examination section also has fairly complete phrases.
Note that only four studies are ordered under the
Diagnostic Workup section; this is acceptable.
This note uses some abbreviations not included in the
list of common abbreviations that is posted at each
writing station, but they are common enough to be
recognizable by the practicing physicians who rate
the notes. The note is written in cursive script, but it
is legible.

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Patient Note Example 1

17

Patient Note Example 2

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APPENDIX D
Clinical Skills Evaluation Collaboration (CSEC) Center Addresses
Travel information about each ___location is available at
www.usmle.org/Examinations/step2/cs/CSECAddresses.html
CSEC Center Atlanta
Two Crown Center
1745 Phoenix Boulevard
Suite 500, 5th Floor
Atlanta, GA 30349
CSEC Center Chicago
First Midwest Bank Building, 6th Floor
8501 West Higgins Road, Suite 600
Chicago, IL 60631
CSEC Center Houston
Amegy Bank Building, 7th Floor
400 North Sam Houston Parkway
Suite 700
Houston, TX 77060
CSEC Center Los Angeles
Pacific Corporate Towers
100 North Sepulveda Boulevard, 13th Floor
El Segundo, CA 90245
CSEC Center Philadelphia
Science Center
3624 Market Street, 3rd Floor
Philadelphia, PA 19104

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