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Student Name __________________________

ICM 1: HTP Recording Review Checklist


Place a check () in the appropriate space that describes your performance.
History
Inquired About Item................asks a question pertaining to item
Failure to Expand on Item When Necessary asks a question about item but fails to ask
suitable follow-up question(s)
Omitted Item...........................does not ask a question pertaining to item
N/A...........................................item is Not Applicable or Not Appropriate for patient or
situation*
*N/A should not mean not assessed.
History
Inqui
red
Abou
t
Item
Chief Complaint and Present Illness:
Chief complaint in patients own words
Duration of each complaint
Location of the symptom
Severity of the symptom
Character of the symptom
Relieving factors
Exacerbating factors
How the symptom started (abruptly, gradually,
intermittently)
Onset and course over time of the symptom
complex
Questions pertinent to other complaints that
are discovered
Associated symptoms
OTHER DATA
Patients age
Past medical history
Allergy to medication
Medications
Family history (including illnesses similar to
the patients)
Marital status/family situation and impact on
illness
Home environment (including who lives there)
and its impact on illness
Functional History (ADL and IADL, for older or

Faile
d to
Expa
nd
Whe
n
Nee
ded

Omit
ted
Item

N/A

Student Name __________________________


frail patients only)
Education/Occupational history
Military History (Did you ever serve in the
military?)
Habits (tobacco current and past, alcohol and
illicit drugs)

General Interview Skills


Well Done................................student has mastered this aspect of the interview
Acceptable...............................students interviewing skills are adequate for a first year
student
Needs Improvement................students interviewing skills are inadequate in this respect
General Interview Skills

Well Done

Accepta
ble

Needs
Improvement

Introduction
Own name clearly stated
Interviewers role established
Patients name established
Nonverbal
Attentive posture
Eye contact
Nonintrusive (still when listening)
Language
Clear, audible diction
No jargon
Begins with open questions
Sparing use of direct questions
No leading or biased questions
Facilitation
Nonverbal nods (uh-huh)
Encouraging statements
Reflection
Clarification/Direction
Clarifies vague terms
Keeps patient on task
Summarizes findings
Invites comments/questions
Key aspects of the encounter
1) Opening the encounter

Not
Done

Don
e

Done Well

N/A

Student Name __________________________


2) Establishing and maintaining rapport
3) Characteristics of the Interview
a) Information gathering
i) Questioning style (open ended, sparing
use of direct)
ii) Pace and flow of questions
iii) Organization
iv) Completeness of the interview
(1) Cardinal elements of the HPI
addressed?
(2) Pertinent aspects of past, family and
social history covered?
b) Listening skills and nonverbal
communication
4) Closing the encounter