Evaluation Of Focused History And Physical Examination Encounter Form

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EVALUATION OF FOCUSED HISTORY AND PHYSICAL EXAMINATION
ENCOUNTER FORM
Student________________________________________ Site______________________ Date_________________
Evaluator________________________________________________
OPD Observation / Feedback / Evaluation:
Please evaluate the student's cases with the following form. (NO = not observed)
Case: ________________________________________________________________________________________
HISTORY TAKING:
Unsatisfactory
Satisfactory
Superior
NO
Ability to take a focused history:
1
2
3
4
5 6
7
8
9
Unsatisfactory:
Inefficient, unfocused, does not ask questions relevant to patient's complaint.
Satisfactory:
Efficient, focussed, asks questions relevant to patient's complaint.
Superior:
Efficient, purposeful, well-focussed, asks questions that are relevant to patient's
complaint and reveal student's understanding of differential diagnosis.
Comments:
Unsatisfactory
Satisfactory
Superior
NO
COMMUNICATION SKILLS:
1
2
3
4
5 6
7
8
9
Unsatisfactory:
Unable to speak to patient in a language that the patient understands, makes patient
uncomfortable, makes inappropriate comments.
Satisfactory:
Puts patient at ease, uses language patient understands.
Superior:
Seems sensitive and compassionate, develops rapport with patient.
Comments:
Unsatisfactory
Satisfactory
Superior
NO
PHYSICAL EXAM:
1
2
3
4
5 6
7
8
9
Unsatisfactory:
Unable to examine patients in a comfortable manner.
Satisfactory:
Does exam with patients at ease.
Superior:
Does organized exams/involves child and parent and explains the process to them.
Comments:
Unsatisfactory
Satisfactory
Superior
NO
ABILITY TO IDENTIFY THE
1
2
3
4
5 6
7
8
9
MAIN ISSUES:
Unsatisfactory:
Does not consider alternative diagnoses.
Satisfactory:
Able to recognize a number of alternatives, including the most relevant.
Superior:
Able to generate a fairly complete list and recognize the most likely/important.
Comments:

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