Background: The National Board of Osteopathic Medical Examiners administers the COMLEX-USA Level 2-PE, an assessment of clinical skills of osteopathic medical students. This evaluation includes developing a patient care plan. Purpose: Based on one simulated case, we investigated the appropriateness and cost of care and quantified their relationship to performance. Methods: Four hundred sixty-seven postencounter notes were coded for appropriateness using expert physician judgments and for cost of care using Centers for Medicare and Medicaid Services data. Various outcome measures were correlated with physician scores. Results: In this case, candidates recommended an average of 5.6 interventions with an average cost of $227 and appropriateness rating of 2.4 on a 1 (indicated) to 4 (potentially dangerous) scale. Total cost and inappropriateness of actions were negatively correlated with candidate scores (r = -.208, p <.0001 and r = -.318, p <.0001, respectively). Conclusions: Results from this investigation provide some evidence to support the validity of physician note ratings of patient care plans and demonstrate the need to include these principles in medical education. © 2012 Copyright Taylor and Francis Group, LLC.