Davao Medical School Foundation, Inc.

Department of Internal Medicine

History Taking Rubric

Name of Student: _______________________________________ Year Level: _________

Preceptor: _____________________________________________ Date: ______________
Instructions: Please rate the following student assigned to you on each of the components of a health
history. Mark a check [ ⁄ ] on the box corresponding to each component.

4 3 2 1 0

Builds a strong
rapport with Mostly Adequate Limited rapport
No attempt at
the patient, establishes rapport but or significant
establishing
Establishing demonstrating rapport with may lack depth lapses in
rapport.
Rapport empathy and some lapses. or consistency. communication.
active listening.

Uses open-
ended Adequate use Limited use of
Mostly uses No attempt at
questions of open-ended open-ended
open-ended using open-
effectively to questions but questions or
Open-Ended questions with ended
encourage may lack unclear
Questions some gaps. questions.
detailed consistency. purpose.
responses.

Asks focused
Mostly asks Limited
and relevant Adequate No attempt at
relevant relevance or
questions based questioning but asking focused
Focused and questions with significant
on the patient's may lack and relevant
Relevant some omissions in
presenting precision. questions.
Questions omissions. questioning.
complaint.

Gathers a
comprehensive Limited
Mostly Adequate No attempt at
history, coverage or
comprehensive coverage but gathering a
covering significant
Thoroughness of with some may lack comprehensive
relevant omissions in
History omissions. thoroughness. history.
systems and history.
details.

Demonstrates a
systematic
Adequate Limited
approach to Mostly No attempt at a
approach but systematic
Systematic history-taking, systematic with systematic
may lack approach or
Approach ensuring no key some lapses. approach.
consistency. significant gaps.
areas are
missed.
 Adheres to
ethical
Demonstrates
standards, Mostly adheres Adequate No
unprofessional
respects patient to standards professionalism demonstration
behavior or
Professionalism autonomy, and with minor but may lack of professional
significant
maintains lapses. consistency. conduct.
lapses.
professionalism
.

Integrates
patient history Mostly Adequate Limited
No attempt at
information integrates integration but integration of
Integration of integrating
effectively to information may lack depth information or
Information patient history.
form a coherent with some gaps. or relevance. inconsistencies.
clinical picture.

Closes the
history-taking
Mostly closes Adequate No attempt at
interaction Limited closing
effectively with closing but may professionally
Closing the professionally or significant
some lack depth or closing the
Interaction and ensures oversights.
oversights. consistency. interaction.
patient
understanding.

Max Score: Total Score: