Part IV, Station by Station

A patient station is 22 minutes on a fixed clock: 2 to read, 14 in the room, 6 to write. Most candidates who struggle don't lack knowledge — they lose the encounter to bad time management. Here's how to spend every minute so the clock works for you.

The door note (2:00): build your plan before you touch the handle

The chart outside the room gives you age, sex, chief complaint, vitals, and setting. Two minutes is enough to walk in with a plan instead of improvising. In your head (or on scratch paper), lock three things:

• A working differential — 3–4 conditions the chief complaint + demographics suggest, ordered most-to-least likely.
• The exam maneuvers that would separate them — decide now which 3–4 tests you'll run, so you're not fishing later.
• A red-flag screen — what would make this not yours to treat? Pre-load the “can't-miss” questions for this presentation.

“Low back pain, 58M” is a different plan than “low back pain, 24F.” The door note is where you commit to a direction. Walk in already hunting.

The interaction (14:00): a budget, not a conversation

Fourteen minutes disappears fast. Budget it out loud in your head as you go:

History — aim for ~7–8 minutes

Run a structured history so you don't miss anything and don't ramble. OPQRST for the complaint (Onset, Provocation/Palliation, Quality, Radiation, Severity, Timing), a focused review of systems, and your red-flag questions. The standardized patient answers only what you ask — vague questions get vague answers, so ask specifically. If you never ask about night pain, weight loss, or bowel/bladder changes when the presentation warrants it, the case will punish you for it.

Exam — aim for ~4–5 minutes

This is where candidates either look competent or look lost. Run the maneuvers you pre-selected from the door note — the ones that actually discriminate your differential — and run them correctly, narrating as you go (“I'm checking a straight-leg raise on the right…”). A focused, purposeful exam beats a frantic head-to-toe every time. Physical examination is one of the five graded domains; a sloppy or scattershot exam costs you there directly.

Report of findings — the last ~2 minutes

Don't let time run out mid-exam and skip this. Close by telling the patient, in plain language, your working diagnosis, your plan, and your disposition (“Based on what I'm seeing, this looks like…, here's what I'd do…, and I'd want you to see… because…”). This is a graded communication moment — clarity and rapport score. A clinically-fine candidate who never explains anything to the patient leaves points on the table.

The SOAP note (6:00): triage, don't transcribe

Six minutes, four fields, 950 characters each. You cannot write everything, so write what matters: the pertinent positives and negatives, the exam findings that drove your thinking, a committed assessment (with the disposition), and a specific plan. Documentation is a scored domain — prioritized, legible, defensible notes earn points; a panicked data-dump doesn't. We break the SOAP down field by field in Writing the Part IV SOAP Note.

Put it together

The stations reward a rhythm, not heroics: plan on the door, budget the room, commit to a disposition, write tight. The only way that rhythm becomes automatic is reps under the real clock — which is exactly what the exam is testing. Before you drill, make sure you know how you're actually graded and how to spot the cases that aren't yours to treat.