Before your first U.S. rotation, observership or residency

Make your first U.S. clinical day feel familiar

Work fictional patient charts, write the assessment and plan, and get attending-style feedback on your reasoning, safety and plan. Or manage a patient on the clock in a Step 3-style simulation. All before your first impression is on the line.

Try a free case See how it works

No signup for the demo · 2 free cases and 2 graded notes on the free plan · no credit card

H&P, SOAP & discharge notes
Step 3 CCS-style simulations
Rubric feedback on 7 dimensions
Fictional patients only

A growing case library
H&P, SOAP and discharge notes
Step 3 CCS-style simulations
Manage a patient on the clock
7 rubric dimensions
Scored on every note
Free to start
No credit card

How it works

Review the chart. Write the note. Get attending-style feedback.

The same loop you will run on a real service, minus the consequences of getting it wrong the first time.

Review the chart
Vitals and trends, problem list, home medications, allergies, labs with high/low flags, imaging, prior notes, and the care team, laid out the way a real EHR lays them out.
Write the note
The assessment and plan, which is what the attending reads first. The full note (HPI, ROS, exam and the rest) is there when you want to practise it. Dot-phrase scaffolds give you the skeleton; the reasoning has to be yours.
Get attending-style feedback
Scored against the case's rubric, with the specific elements you missed, the safety concerns you left open, rewrite suggestions, and an ideal note to compare against.

Chest Pain Admission · H&P

Fictional patient

James T. · 58 male · Chest pain for 2 hours

148/92

SpO2

97%

Troponin I: 0.08 ng/mL (high)

ECG: 1mm ST depression, V4-V6

HPI: Substernal chest pressure, radiates to left arm, diaphoresis...

Scored on the same 7 dimensions, every note:

Completeness
Organization
Clinical Reasoning
Assessment & Plan Quality
Documentation Style
Case Fact Alignment
Safety

Try the pneumonia case

What changes

Strong notes are not longer. They are clearer.

The same fictional pneumonia admission, documented two ways.

Before

Assessment:

Pneumonia.

Plan:

Antibiotics. Oxygen. Monitor.

Correct, and almost useless to the next clinician. It records a conclusion without the reasoning that led there, and a plan nobody can act on or escalate from.

After

Assessment:

Community-acquired pneumonia with mild hypoxia, supported by fever, productive cough, leukocytosis, and right lower-lobe infiltrate. Currently hemodynamically stable without shock physiology.

Plan:

Start antibiotics per local protocol, continue oxygen and wean as tolerated, trend respiratory status and WBC, follow cultures if obtained, and reassess for worsening hypoxia, hypotension, confusion, or persistent fever.

Same diagnosis. Now it shows what the evidence was, what the patient is not, and what would change the plan, so the next clinician can pick it up.

The goal is not a longer note. It is a note that shows clinical reasoning and can guide whoever reads it next.

Write your own in the demo

Two ways to practise

Write the note. Or run the case on the clock.

Documentation is what you are judged on every day. Case management under time pressure is what Step 3 and your first nights on call test. Practise both.

Note cases

Clinical documentation

Review a fictional chart, write the assessment and plan, and get scored on the same 7-part rubric every time, with an ideal note to compare against.

H&P. The admission story, differential, problem list and first plan.
SOAP. What changed overnight, what the trend means, and today's plan.
Discharge Summary. Hospital course, medication changes, follow-up and return precautions.

Try a free case

No signup. 2 cases are free.

Simulations

Step 3 CCS-style case management

Manage a patient on a simulated clock: examine, order, move them between office, ED, ward and ICU, and watch them change whether or not you act.

A free-text order sheet, the way real order entry works
Results arrive when they realistically would, not instantly
Order what you need once you have a diagnosis; only time-critical treatments are scored on speed
A full debrief: what was expected, what you missed, what would have caused harm

Explore simulations

2 simulations are free with an account.

Clinic follow-up, consult and ED decision-making notes are taught in the Learning Hub today; practice cases for them are not built yet.

The hidden curriculum

Exams prepare you for questions. Rotations test your workflow.

You can know the medicine and still hesitate when the chart opens. What belongs in the HPI and what belongs in the assessment? What does a plan need before an attending trusts it? Nobody teaches that part. You are expected to already know it.

“Will my note sound U.S.-style?”

Practise the structure, phrasing and problem-based thinking before a rotation, not during one.

“What if I miss something important?”

Feedback names the safety gaps, the missing data and the parts of the plan that stop short.

“What will the attending think?”

See how your reasoning reads from the evaluator's side, against the same rubric every time.

“I know the medicine. The workflow is different.”

Rehearse chart review, documentation and case management in one continuous loop.

Built for IMGs preparing for USCE, observerships and residency, and just as useful for a U.S. student before clerkships or an incoming intern. If you have never written a U.S.-style note, you are not behind. You just need somewhere safe to learn it before a team is watching.

Try a free case

Why it matters

The AAMC's Core Entrustable Professional Activities for a new resident include documenting a clinical encounter in the patient record. AAMC
Program directors weigh more than exam scores, including feedback from residents who worked with you. NRMP
ECFMG certification is central to how IMG qualifications are evaluated for U.S. graduate medical education. ECFMG

Cosign does not guarantee interviews, letters, rank position or Match outcomes, and is not endorsed by or affiliated with these organizations.

Learning Hub

Learn the note. Then prove it in a case.

A growing curriculum on the anatomy of strong U.S. documentation: how to write a concise HPI, summarise labs without dumping data, build an assessment that shows reasoning, and write a plan that is specific and safe.

Foundations

What a U.S. note is for, and who actually reads it

Note Sections

HPI, ROS, exam, labs, assessment and plan, one at a time

Note Types

H&P, SOAP, discharge, consult, clinic and ED

Clinical Reasoning

Turning findings into an assessment you can defend

Common Mistakes

The errors attendings flag most, and why

Before/After Notes

The same note written weakly and well, side by side

Rubric & Scoring

How your note is judged, before it is judged

Practice Drills

Short exercises on one section at a time

Every lesson links straight into a case

Price

Free to try. From $24.92 a month for everything.

Start without an account. Subscribe monthly, or for 3, 6 or 12 months at a lower monthly price, and cancel any time from your billing page.

Free

2 cases, no signup needed for the demo
2 simulations with a free account
2 graded notes with full rubric feedback
The full Learning Hub

Try a free case

Full access

$49 / month

Or $299 for 12 months, $24.92 a month.

Every case and simulation, plus new ones as they are added
50 graded notes every month
Ideal notes and rewrite suggestions on every graded note
Cancel any time and keep access to the end of the period

See plan details

Early access pricing, which may change.

Questions

The things people ask before signing up.

Is this a real EMR?: No. It is an educational simulation using entirely fictional patients. It is not a medical device, not an electronic health record, and not for real patient care.
Can I enter real patient information?: Never. Submissions are screened for likely real-patient information and blocked when the screen is confident, but the rule stands regardless of the screen: fictional patients only.
Will this guarantee residency or interviews?: No. It is practice for documentation and clinical workflow. Anyone promising you a Match outcome is selling you something they cannot deliver.
Who is this for?: It was built for IMGs preparing for USCE, observerships, externships, residency or fellowship, and that is still the audience it fits best. It works just as well for a U.S. medical student before clerkships, or any incoming intern who wants the documentation workflow to be familiar rather than new.
What are the simulations?: Step 3 CCS-style cases where you manage a patient on a simulated clock: examine, place orders, move them between office, ED, ward and ICU, and see results when they would realistically come back. They are scored on what you ordered and whether anything would have caused harm, not on writing.
What feedback do I actually get?: A score on each rubric dimension with the reasoning behind it, the specific elements you left out, safety concerns graded by severity, section-level rewrite suggestions, and an ideal note to compare against.
Is a real attending reading my note?: No. The feedback is generated by an AI model grading your note against the rubric written for that specific case, then set beside an ideal note authored for it. "Attending-style" describes the rubric and the tone, not a human reviewer. It is a learning aid, and like any model it can be incomplete or wrong.
What if I am early in my preparation?: Start with a Level 1 case and the Learning Hub foundations. The Level 1 cases exist to teach the shape of the note before the medicine gets complicated.
What if I already have clinical experience?: Go straight to Level 2 and 3, where the patient is unstable or the diagnosis is genuinely uncertain, and use replays to push your rubric scores up.
Does this replace real U.S. clinical experience?: No, and it is not meant to. It helps you arrive at that experience already knowing the workflow.

Walk into your next rotation with the workflow already practised.

Open a fictional patient chart, write the note, and get feedback while the stakes are still imaginary.

Try a free case

No credit card. Fictional patients only.