Evaluation Form for Intern Observed Physical Examination
Intern: ________________________
Patient Demographics: Age: ________
Date: _____________________
Gender: _________
Habitus: S
M L XL
Chief Complaint/Dx: ___________________________________________
Please circle one:
Bedside Manner
Does Intern exam as he/she proceeds?
Does intern consider patient comfort/modesty?
Does intern answer patient questions appropriately?
poor
Yes
Yes
Yes
fair
No
No
No
good
excellent
For the following, please CHECK if done and CIRCLE if any problems (technique) were noted during the
examination. Use N/A to signify that a particular component of the examination was not performed.
HEENT
___ Fundoscopic
___ EOM, pupillary response
___ palpate cranium
___ nasal exam
___ examination of external & middle ear
___ oropharyngeal exam
___ palpation of neck
___ thyroid exam
___ inspect for JVD
___ auscultate for carotid bruits
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
CHEST/PULM:
___ inspection
___ palpation
___ auscultation
___ percussion
___ tracheal palpation
CARDIAC:
___ inspection
___ palpation
___auscultation of 4 major areas
ABDOMINAL:
___ inspection
___ palpation (light and deep)
___ percussion
___ auscultation
___ maneuvers to accentuate abnormalities
___ CVA tenderness
___ checks femoral pulses; listen for bruits
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
EXTREMITIES/SKIN:
___ inspection (including accurate verbal description of skin/nail chgs)
___ comments on muscle bulk, atrophy or signs of physical trauma
___ check for peripheral pulses
___ accurately assesses cyanosis/capillary refill
___ can identify signs of chronic peripheral vascular disease
___palpation of joints, checking for effusions
___ testing for knee joint stability
___ can accurately describe any joint abnormality
___ testing for sciatic irritation (SLR)
___ assesses for edema and accurately rates it (if present)
___ can identify clubbing
NEUROLOGIC:
___ knows how to perform MMSE
___ comments on any abnormal movement disorders
___ cranial nerve testing
___ deep tendon reflexes
___ cerebellar testing
___ evaluates gait appropriately
___ accurately rates muscle strength
___ comments on muscle tone; recognizes spaticity/rigidity
___ plantar reflex
___ appropriate sensory examination (pain, microfilament, temp)
___ proprioception testing
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
NOTE:
Genitourinary examination testing will be performed at a later date; but have intern explain how they
would perform:
___ prostate/rectal exam
___ inguinal hernia testing
___ scrotal examination
___ breast examination
___ pelvic speculum exam
___ bimanual palpation of cervix, ovaries, uterus
___ how to obtain a pap smeer
________________________________
Supervising Attending or Chief
_________________
Date
Evaluation form for intern chart stimulated review
Intern: ________________________
Setting:
Inpatient
Date: _____________________
Outpatient
Primary Diagnosis: ___________________________________________
1. CC/HPI: Were the salient presenting symptoms of this patient adequately represented?
YES
NO
Comments: _______________________________________________________________
2. PMHx: Were pertinent positive and negatives documented?
YES
NO
Comments: _______________________________________________________________
3. Were the following reported in appropriate depth?
Family Hx
Yes ____
No ____
Social Hx
Yes ____
No ____
Medications
Yes ____
No ____
Surgical Hx
Yes ____
No ____
Allergies
Yes ____
No ____
ROS
Yes ____
No ____
4. Please comment on the completeness of the PE report:
____________________________________________________________________________
____________________________________________________________________________
5. Were the initial lab/diagnostic studies ordered and interpreted appropriately?
YES
NO
Comments: _______________________________________________________________
6. Was a thoughtful differential diagnosis generated and discussed?
YES
NO
Comments: _______________________________________________________________
7. Was the therapeutic plan logical and well-described?
YES
NO
Overall evaluation for Observed H&P + Chart Stimulated Review
___ Exceeded expectations for level of training
___ Met expectations for this level of training
___ Minor deficiencies noted and discussed with interns
___ Major deficiencies noted, needs to repeat this exercise after remediation
Final Comments:
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________________________
Supervising Attending or Chief
_________________
Date