Student Name _______________________________________________________

Clinical Skills
Performance Based Assessment
Adult History and Physical Examination
Well Patient Encounter

History

Communication Skills/Professionalism**

Y N
□ □ Maintain patient’s privacy (e.g., knock, close door, appropriate draping)**
□ □ Greet patient appropriately**
□ □ Establish reason for visit (Chief Complaint)**
□ □ Outline agenda for visit to patient**

Past Medical History

Y N
□ □ Obtains past medical history
□ □ Obtains past surgical history
□ □ Obtains past hospitalizations
□ □ If female, ask about menstrual history ( and pregnancy history if applicable).
□ □ Allergies (have pt describe reaction)
□ □ Medications (include OTC and herbal preparations), with dose
□ □ Immunizations (Student should ask about specific age-appropriate immunizations)
□ □ Minimal pause between items*

Social History

Y N
□ □ Educational level
□ □ Occupational history/exposures
□ □ Current living arrangements
□ □ Nutrition/diet
□ □ Tobacco, alcohol, recreational drug use
□ □ Sexual history (Partners, Practices, Protection, h/o STDs, & prevention)
□ □ Hobbies/interests
□ □ Travel history
□ □ Cultural background
□ □ Religious preference, if any
□ □ Minimal pause between items*
Student Name _______________________________________________________

Family History

Y N
□ □ Immediate family: age, health status; if appropriate, cause of and age at death
□ □ History of disease (asks specifically about the following: asthma, arthritis, cancer,
diabetes, glaucoma, heart disease/stroke, HTN, hypercholesterolemia, kidney
disease, mental illness, sickle cell disease, seizures, thyroid disease, TB)
□ □ Minimal pause between items*

Review of Systems

Y N
□ □ Performs a 12 point ROS using checklist (avoids medical jargon)
Resource used: ____________________________

Health Maintenance Education

Y N
□ □ Explain rationale for health maintenance
□ □ Formulate a plan for age-appropriate health maintenance, including at least 4 items
1. _________________________
2. __________________________
3. __________________________
4. __________________________

□ □ Ask if there is anything else the pt would like to discuss

Physical Exam
General

Y N
□ □ Wash hands or uses alcohol gel prior to exam
□ □ Throughout the exam, demonstrate a professional manner by conveying concern for
patient’s comfort and privacy
□ □ Notes at least 6 of the following:
• Level of physical and emotional distress, body language
• Level of mental alertness
• Mobility: gait, use of assist devices, etc.
• Body habitus
• Nutritional status
• Grooming
• Difficulty hearing, vision problems
• Speech pattern
Student Name _______________________________________________________

Vital Signs

Y N
□ □ Obtain height and weight (Student should mention they would note height and weight)
□ □ Correctly obtain temperature, pulse, respirations (report HR: ___RR:___ )
(may state that they would obtain temperature)
□ □ Obtain blood pressure in both arms, first checking pulse to rule out auscultatory gap
Right____/_____ Left ____/_____
□ □ Assess pain using 10 point pain scale
□ □ Assess distance vision using Snellen chart (Have student explain procedure)
□ □ Minimal pause between items*

Patient is seated on examining table, wearing a gown, with examiner standing in front of
patient.

Head and Face

Y N
□ □ Inspect skin characteristics, noting color, and texture
□ □ Correctly describes any skin lesions with appropriate terms
□ □ Inspects configuration of skull
□ □ Inspect and palpate scalp and hair for texture, distribution, quantity
□ □ Palpate facial bones
□ □ Palpate frontal, ethmoid, and maxillary sinus regions; if tender, transilluminate
□ □ Palpate temporomandibular joint while patient opens and closes mouth
□ □ Palpate temporal arteries, noting course, thickening, and tenderness
□ □ Correct order was maintained-Inspect, then palpate *
□ □ Minimal pause between items*

Eyes

Y N
□ □ Inspect lids, lashes, sclera, conjunctiva, and iris
□ □ Assess visual fields by confrontation
□ □ Inspect pupils for symmetry and test response to light and accommodation
□ □ Perform corneal light reflex to assess ocular alignment
□ □ Ophthalmoscopic examination, identifying red reflex and inspecting lens, disc, cup
margins, macula, vessels, and retina (should dim the lights)
□ □ Palpate lacrimal apparatus
□ □ Correct order was maintained-Inspect, palpate *
□ □ Minimal pause between items*
Student Name _______________________________________________________

Ears

Y N
□ □ Inspect alignment and placement
□ □ Palpate auricles and mastoid areas
□ □ Otoscopic exam, inspecting canals and tympanic membrane landmarks, deformities, and
inflammation
□ □ Perform Weber and Rinne tests
□ □ Correct order was maintained*
□ □ Minimal pause between items*

Nose

Y N
□ □ Inspect structure and note position of septum
□ □ Determine patency of each nostril
□ □ Inspect mucosa, septum, and turbinates with nasal speculum
□ □ Correct order was maintained-Inspect, palpate *
□ □ Minimal pause between items*

Mouth and Pharynx

Y N
□ □ Inspect lips, buccal mucosa, gingiva, hard and soft palates, tongue, floor of mouth
for color and surface characteristics
□ □ Inspect oropharynx: Note anteroposterior pillars, uvula, tonsils, posterior pharynx,
mouth odor
□ □ Inspect teeth for color, number, surface characteristics
□ □ Palpate tongue and floor of mouth
□ □ Correct order was maintained-Inspect, palpate *
□ □ Minimal pause between items*

Neck

Y N
□ □ Inspect for symmetry and smoothness of neck and thyroid
□ □ Inspect for jugular venous distention
□ □ Palpate carotid pulses, one at a time, noting intensity, contour
□ □ Palpate tracheal position
□ □ Palpate thyroid for size, shape, consistency, tenderness, and nodules using both the
anterior and posterior approaches
□ □ Ausculate carotid arteries and thyroid with bell and diaphragm
□ □ Q: “A thyroid bruit is pathognomonic for what disease?” A: Grave’s Disease.
□ □ Correct order was maintained-Inspect, palpate, auscultate *
□ □ Minimal pause between items*
Student Name _______________________________________________________

Patient is still seated on examining table. Gown is pulled down to the waist for males so the
entire chest and back are exposed; for females, back is exposed, but breasts are covered.

Back and Posterior Chest

Y N
□ □ Inspect skin and thoracic configuration
□ □ Inspect symmetry of shoulders and musculoskeletal development
□ □ Inspect, palpate, and percuss spine
□ □ Press on midpoint of supraspinatus to detect hyperalgesia.
□ □ Palpate and percuss costovertebral angle
□ □ Correct order was maintained-Inspect, palpate, *
□ □ Minimal pause between items*

Lungs

Y N
□ □ Inspect respirations for rate, depth, pattern, I:E ratio (normal 1:2)
□ □ Palpate for chest wall excursion
□ □ Palpate posterior and lateral chest walls for tactile fremitus
□ □ Percuss posterior and lateral chest walls systematically for resonance
□ □ Percuss for diaphragmatic excursion (Normal 3-5 cm)
□ □ Auscultate breath sounds systematically, noting characteristics and presence of
adventitious sounds
□ □ Auscultate for egophony
□ □ Q: “What do E to A changes indicate?” A: Lobar consolidation, possibly pneumonia
□ □ Auscultate for whispered pectoriloquy
□ □ Correct order was maintained-Inspect, palpate, percuss, auscultate *
□ □ Minimal pause between items*

Examiner moves around to the front of the patient. The gown is now lowered in females to
expose the anterior chest. For auscultation of the heart, pt should lean slightly forward.
Student Name _______________________________________________________

Anterior Chest, Lungs, and Heart

Y N
□ □ Inspect skin, musculoskeletal development, symmetry
□ □ Inspect respiratory effort
□ □ Palpate chest wall for tenderness
□ □ Palpate chest wall for tactile fremitus
□ □ Percuss systematically for resonance
□ □ Auscultate systematically for breath sounds
□ □ Auscultate for heart sounds in each of the auscultatory areas with both diaphragm and
bell, timing heart sounds with carotid pulse
□ □ Note rate and regularity of heart sounds
□ □ Note intensity and any splitting of S1 and S2
□ □ Note presence of any extra heart sounds (murmur, click, rub, S3 or S4)
□ □ Correct order was maintained-Inspect, palpate, percuss, auscultate *
□ □ Minimal pause between items*

Assist the patient into a supine position with head of bed elevated about 30o. Pull up/out
footrest.

Neck Vessels and Heart

Y N
□ □ Pull up/out foot rest for patient comfort
□ □ Inspect jugular venous waveform, right side, noting A/V waves, X/Y descents
□ □ Inspect chest for pulsations or heaving
□ □ Perform abdominojugular test (hepatojugular reflux)
□ □ Palpate precordium for thrills or heaves
□ □ Palpate left chest to localize apical impulse, noting position and diameter
□ □ Auscultate systematically in each of the auscultatory areas with diaphragm and bell
□ □ With patient in the left lateral decubitus position, auscultate apex with bell
□ □ Correct order was maintained-Inspect, palpate, percuss, auscultate *
□ □ Minimal pause between items*

Lower head of bed so pt is lying flat. Pull up/out footrest. Cover chest with the pt’s gown.

Y N
□ □ Demonstrate proper draping technique in exposing abdomen from pubis to epigastrium
Student Name _______________________________________________________

Abdomen

Y N
□ □ Inspect skin characteristics, contour, pulsations, movement, and hernias; have patient
raise the head as you inspect abdominal musculature
□ □ Auscultate all quadrants for bowel sounds
□ □ Auscultate the aorta and renal, iliac, and femoral arteries for bruits or venous hums
□ □ Percuss all quadrants for tone
□ □ Percuss liver borders and estimate span (Normal 6-12 cm)
□ □ Percuss left midaxillary line for splenic dullness
□ □ Palpate lightly, all quadrants
□ □ Palpate deeply, all quadrants
□ □ Exclude rebound tenderness
□ □ Q: “What does rebound tenderness suggest?” A: Peritoneal inflammation
□ □ Palpate the umbilical ring and any previous incision sites for hernias
□ □ Palpate right costal margin for liver border
□ □ Palpate left costal margin for spleen
□ □ Palpate for kidneys
□ □ Palpate midline for aortic pulsation
□ □ Correct order was maintained-Inspect, auscultate, percuss, palpate *
□ □ Minimal pause between items*

Patient continues to lie supine on exam table

Musculoskeletal

Y N
□ □ Perform straight leg raise on both sides
□ □ Q: “Where does the discomfort occur to indicate a positive straight leg test?” A: Pain
radiating past the leg when the leg is raised 60 degrees
□ □ Flex each hip and knee
□ □ Feel for crepitus in the patella-femoral joint and knee
□ □ Palpate the knee for warmth and swelling
□ □ Check the patellar tap
□ □ Look at the feet for abnormalities and examine soles for calluses and ulcers.

Have pt return to a seated position with legs dangling off the side of the exam table.

□ □ Observe pt moving from a lying to a seated position, noting coordination, use of

muscles, ease of movement
□ □ Inspect skeleton and extremities for symmetry, alignment, contour, size, gross
deformities, and joint effusion
□ □ Inspect musculature for symmetry, size, tone, fasciculations, and spasms
□ □ Evaluate the active range of motion for all major joints; if active ROM abnormal,
assess passive ROM
Student Name _______________________________________________________

□ □ Palpate all bones, joints, and surrounding musculature for warmth, tenderness,
effusion, and crepitus. Must do 15 of the following: neck, shoulder, humerus,
elbow, radius/ulna, wrist, hand, MCP, PIP, DIP, fingers, hips, femur, knees,
tibia/fibula, ankles, MTP, first toe joint)
□ □ Evaluate motor strength for major muscle groups. Must do 11 of the following: biceps
(C5,C6), triceps (C6-8), Grip (C7-8, T1), finger abduction (C8, T1, ulnar n.), thumb
opposition (C8,T1), Hip flexion (L2-L4), Hip Extension (S1), Hip Abduction (L4-5,
S1), Hip Adduction (L2-4), Knee flexion (L4,L5, S1,S2), Knee extension (L2-L4),
Ankle dorsiflexion (L4-5), Ankle plantar flexion (S1)

□ □ Ask the patient to put his hands behind his head with the elbows going back.
□ □ Have the patient place the elbows at the side of his body and bend them 90 degrees.
□ □ Turn the palms up and down.
□ □ Ask the patient to bend the arms and touch the shoulders.
□ □ Show him how to make a “prayer sign” bend the wrist back as far as possible.
Then have the put the back of the hands together in a similar fashion.
□ □ Have the patient put his arms straight out in front of his body.
□ □ Have the patient clench and then open his hands flat.
□ □ Inspect the hands and fingers carefully for full extension and any abnormalities.
□ □ Ask him to squeeze your index and middle finger.
□ □ Have the patient touch each fingertip with their thumb.
□ □ Gently squeeze the patient’s MCP heads.
□ □ Correct order was maintained-Pt was kept in proper position *
□ □ Minimal pause between items*

Extremities/Lymphatics

Y N
□ □ Inspect skin for color, swelling, and masses
□ □ Inspect nails for clubbing, characteristics
□ □ Palpate extremities for edema
□ □ Palpate lymph nodes. Must do 10 of the following: occipital, preauricular,
postauricular, tonsillar, submandibular, submental, posterior cervical chain, anterior
cervical, supraclavicular, infraclavicular, axillary, epitrochlear, and inguinal lymph
nodes.
Palpate extremities for pulses
□ □ Brachial
□ □ Radial
□ □ Femoral- (may show you where they would feel)
□ □ Popliteal
□ □ Posterior tibialis
□ □ Dorsalis pedis
□ □ Correct order was maintained-Pt was kept in proper position *
□ □ Minimal pause between items*
Student Name _______________________________________________________

Neurologic

Test cranial nerves

Y N
□ □ Test sense of smell (CN I)
□ □ Near vision screening using Rosenbaum chart or newsprint (CNII)
□ □ Test extraocular eye movements (CN III, IV, VI)
□ □ Test light touch sensation of forehead, cheeks, chins (CN V)
□ □ Inspect ability to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile,
and puff out cheeks (CN V, VII)
□ □ Assess hearing with whisper test or ticking watch (CN VIII)
□ □ Test gag and “ah” reflexes (CN IX, X)
□ □ Test shoulder shrug (CN XI)
□ □ Inspect tongue for color, characteristics, symmetry, movement (CN XII)
□ □ Minimal pause between items*

Test primary sensory functions, including:

Y N
□ □ Sharp/dull sensation on face, lower arms, hands, lower legs, and feet
□ □ Vibratory sensation of distal extremities
□ □ Protective sensation of feet with 10 gram monofilament

Test cortical sensory functions, including:

□ □ Graphesthesia
□ □ Stereognosis
□ □ Two-point discrimination

Assess deep tendon reflexes, noting any clonus, if present, including:

□ □ Brachioradial
□ □ Biceps
□ □ Triceps
□ □ Patellar
□ □ Achilles
□ □ Plantar reflex (Babinski)
□ □ Minimal pause between items*
Student Name _______________________________________________________

Prioprioception and cerebellar function:

Y N
□ □ Position sense of upper and lower extremities
□ □ Rapid, alternating movements
□ □ Finger-to-nose
□ □ Heel-to-shin
□ □ Assist pt to a standing position. Examiner stands next to pt.
□ □ Balance – Romberg and/or stand on one foot with eyes closed > 5 sec
□ □ Observe gait, both normal gait and heel-to-toe walking
□ □ Correct order was maintained-Pt was kept in proper position *
□ □ Minimal pause between items*

Memory & Cognition

Y N
□ □ What is the date (month, date, year) and time of day?
□ □ What city, state, and building are we in?
□ □ What season is it?
□ □ Three word recall
□ □ Serial 7’s
□ □ Remote memory (current President and past 4)
□ □ Comprehension (Follow 3 step command, “Please do what I say”)
□ □ Draw a clock
□ □ Draw the following:

□ □ Write a sentence.
□ □ Minimal pause between items*
Student Name _______________________________________________________

Communication Skills/Professionalism**

Y N
□ □ Dressed appropriately
□ □ Prior to meeting pt, insure that all necessary equipment is readily available
□ □ Avoid directive/leading questions
□ □ Give pt opportunity/time to talk
□ □ Listen and give pt undivided attention (face pt, give verbal acknowledgement)
□ □ Check/clarify information (e.g., recap, ask “how much”)
□ □ Encourage pt to ask questions/check understanding
□ □ Adapt to pt’s level of understanding (e.g., avoid/explain jargon)
□ □ Expresses caring, concern, empathy
□ □ Maintains a respectful tone
□ □ Recaps encounter and plan back to the patient
□ □ Thanks patient for their time
□ □ Cleans up clinic room back to original state

Y: Examiner performs correctly without prompting from evaluator. 1 point

N: Examiner requires correction on technique or prompting. 0 points
 Student Name _______________________________________________________

Student’s Docent _______________________ Time to complete exam _________

Name of volunteer _______________________________________________________

0 1 2 3 4
Competency
Fail Marginal Pass Satisfactory Pass High Pass Honors
History taking/ Always required Often required Occasionally Rarely required Never required
Physical exam correction or correction or failed to required correction or failed correction and
Skills failed to perform perform elements of correction or failed to perform never failed to
elements of H&P H&P about 40% of to perform elements of H&P perform
199 total the time elements of H&P about 10% of the elements of H&P
points about 30% of the time 5% or less of the
time time

Missed 79 or more Missed 59-80 Missed 21-60 Missed 11-20 Missed 0-10
points

Communication Always begins Often begins with Occasionally Rarely begins with Always begins
Skills & with directive/leading begins with directive/leading with open-ended
Professionalism directive/leading questions; often directive/leading questions; rarely questions; always
questions; interrupts patient. questions; interrupts patient; gives patient an
18 points constantly Often failed to clarify occasionally Rarely failed to opportunity to talk.
interrupts patient; answers, Often used interrupts patient; clarify answers, Always clarified
Failed to clarify jargon. Occasionally failed Rarely used jargon. answers, Never used
answers, Always to clarify answers, jargon.
used jargon. Occasionally used
jargon.

**Missed > 8 in **Missed 6-7 in the **Missed 3-5 in **Missed 1-2 in the **Missed 0 in the
the first and last first and last the first & last first & last sections. first & last sections.
sections. sections. sections.

Flow Always pauses Often pauses Occasionally Rarely pauses Never pauses
between between pauses between between between
34 points items/sections items/sections items/sections items/sections items/sections

Nearly always Often failed to Occasionally failed Rarely failed to Always

failed to demonstrate a to demonstrate a demonstrate a demonstrates a
demonstrate a logical sequence to logical sequence to logical sequence to logical sequence to
logical sequence to H&P H&P H&P H&P
H&P
*Missed 15-34 of *Missed 11-14 of the *Missed 4-10 of *Missed 1-3 of the *Missed 0 of the
the flow or flow or sequence the flow or flow or sequence flow or sequence
sequence boxes. boxes. sequence boxes. boxes. boxes.

Score for History Taking/Physical Exam Skills _______

Score for Communication Skills _______
Score for Flow of Exam _______
Mean Composite Score _______
Student Name _______________________________________________________

Given appropriate expectations for this student’s level of training, I would feel comfortable with
this student participating in the care of my patients:
□ Agree □ Disagree

What did the student do well?

List areas to focus on for continued improvement:

Signature of examiner___________________________________ Date_____________

*PLEASE REMIND STUDENT TO FILL OUT COURSE EVALUATION ON OASIS*