clerkship handbook - University of Hawaii – Department of Medicine

U.H. John A. Burns School of Medicine
Third-Year Clerkship in Internal Medicine
OBSERVED HISTORY AND PHYSICAL
Evaluation Form
INSTRUCTIONS:
o The Observed History and Physical should be scheduled by halfway through the inpatient block.
o The Chief Medical Resident should select a patient who is unknown to the student.
o The student must perform the Observed History and Physical by memory.
o The student should try to finish the Observed History and Physical in 1 hour.
o The student must turn in at least one (1) completed Observed History and Physical Evaluation Form to the
Hospital Site Coordinator.
Student_____________________________________________ Hospital (circle): KMC QMC TAMC
Start Time ____:____
Faculty (Chief Resident) _______________________________ Date_____________ End Time ____:____
TOTAL Time ____:____
A. PATIENT-PHYSICIAN RELATIONSHIP
Observe whether and how the student:
Maximum Score
Student’s Score
1. Introduces self to the patient and explains his/her role correctly 2 ( )
2. Attends to the patient’s privacy and comfort 3 ( ) before beginning
and throughout the history and physical
3. Demonstrates effective listening skills 5 ( )
(appropriate use of eye contact, posture, pauses/silence, etc.)
4. Demonstrates effective verbal skills 5 ( )
(appropriate use of open- and closed-ended questions,
repetition, clarifying, restating, explanation, interpretation, etc.)
5. Uses language that the patient understands 5 ( )
B. INTERVIEW
Observe whether and how the student:
1. Obtains the patient’s complete history 5 ( )
systematically and completely
2. Balances allowing the patient to speak while 5 ( )
directing questions to efficiently obtain a
clear and accurate history in the time available
3. Elicits the history of the present illness (HPI) 10 ( )
systematically and completely
4. Delineates major symptoms systematically and completely 5 ( )
(location, radiation, quality, intensity, setting, onset, duration, frequency
setting, aggravating and alleviating factors, associated manifestations,
functional impairment, patient’s interpretation of symptoms, etc.)
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