History And Physical Assignment Evaluation Form
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1HISTORY AND PHYSICAL ASSIGNMENT EVALUATION FORM
The student is responsible for making a timely and convenient appointment with the faculty member who worked on
this case with them to meet and review this written history and physical. The faculty is to grade this written H&P
and give it to the student at the end of said meeting. It is the student’s responsibility to take this completed
evaluation form and the written H&P and turn them in to the clerkship coordinator.
Student Name:____________________
Evaluator Name (Attending who worked on this case with you):____________________
Evaluator Signature:__________________
PATIENT CARE
A. HISTORY TAKING: | 1 2 3 | 4 5 6 | 7 8 9 |
Did the history capture all the necessary elements of the case, including pertinent positives and negatives for
this presentation?
Additional comments (optional)?
B. PHYSICAL EXAM: | 1 2 3 | 4 5 6 | 7 8 9 |
Was the student’s examination appropriate for the presentation, including focus and expansion of core
examination where appropriate?
Additional comments (optional)?
C. CLINICAL JUDGEMENT/DECISION MAKING/PROBLEM SOLVING: | 1 2 3 | 4 5 6 | 7 8 9 |
Did the student’s assessment include appropriate localization and diagnosis or differential diagnoses?
Did the student show evidence of advanced knowledge of evaluation, management, and/or counseling?
Additional comments (optional)?
MEDICAL KNOWLEDGE: | 1 2 3 | 4 5 6 | 7 8 9 |
Did the student show a strong knowledge base in the assessment?
Additional comments (optional)?
INTERPERSONAL COMMUNICATIONS (C: WRITTEN MEDICAL RECORD): | 1 2 3 | 4 5 6 | 7 8 9 |
Was the student’s history, examination, and assessment clear, complete, pertinent, and well composed?
Additional comments (optional)?
FEEDBACK ADVICE:
What was the best thing about this student’s history and physical examination write-up?
What is at least one thing this student could do in future to improve their written H&Ps?
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