Evaluation Form - History
Following a "performance," the standardized patient completes a history evaluation form. Below is a sample history evaluation form.
Patient-Centered Process
( ) Yes ( ) No Appropriate introduction/greeting
( ) Yes ( ) No Began with and used other open-ended questions
( ) Yes ( ) No Used closed-ended questions for clarification
( ) Yes ( ) No Avoided complex or leading questions
( ) Yes ( ) No Avoided multiple questions
Facilitating Skills
( ) Yes ( ) No Speech clear
( ) Yes ( ) No Language clear (no jargon)
( ) Yes ( ) No Avoided disruptive Note-taking
( ) Yes ( ) No Attended to patient’s non-verbal communication
( ) Yes ( ) No Used silence and nonverbal encouragement
( ) Yes ( ) No Used facilitative techniques (echoing, reflection, neutral utterances, paraphrasing)
( ) Yes ( ) No Used emotion-handling skills during interview (understanding/legitimation, respecting/praising, supporting/partnership)
History of Present Illness
( ) Yes ( ) No Chief complaint in patient’s own words
Symptoms patient experiencing
( ) Yes ( ) No Location
( ) Yes ( ) No Radiation
( ) Yes ( ) No Character
( ) Yes ( ) No Severity
( ) Yes ( ) No Associated Symptoms
( ) Yes ( ) No Onset
( ) Yes ( ) No Duration
( ) Yes ( ) No Aggravating factors
( ) Yes ( ) No Relieving factors
( ) Yes ( ) No Impact of illness on patient and others
( ) Yes ( ) No Patient’s concerns about illness
( ) Yes ( ) No Health issues (ethical-social-spiritual, functional, health promotion, health hazards)
Past Medical History
( ) Yes ( ) No Hospitalizations
( ) Yes ( ) No Other medical problems
( ) Yes ( ) No Major diseases
( ) Yes ( ) No Medications
( ) Yes ( ) No Allergies
( ) Yes ( ) No Menstrual/OB history
Personal/Social History
( ) Yes ( ) No Current personal situation
( ) Yes ( ) No Other personal factors (smoking, alcohol)
Family History
( ) Yes ( ) No Family history of present illness
( ) Yes ( ) No Specific diseases (diabetes, hypertension, high cholesterol)
Review of Systems
( ) Yes ( ) No Review of systems (questions related to the function of relevant systems)
Transition to Physical Exam
( ) Yes ( ) No Summarized history
( ) Yes ( ) No Asked patient if she/he had any questions
( ) Yes ( ) No Answered patient’s questions clearly
( ) Yes ( ) No Appropriate transition to physical exam
Global Assessment
Overall, how satisfied were you with this student’s history taking skills?
( ) extremely dissatisfied
( ) very dissatisfied
( ) dissatisfied
( ) satisfied
( ) very satisfied
( ) extremely satisfied
Following a "performance," the standardized patient completes a history evaluation form.Following a "performance," the standardized patient completes a history evaluation form.