TTD 1: Performing and presenting a basic history and physical examination
- This EPA focuses on clinical assessment, verifying the skills achieved in medical school, including performing a basic history and physical examination and presenting the case.
- This EPA does not include correct diagnosis, management, or communication of the plan with the patient/family.
Direct observation of the history and physical by supervisor or senior resident
Use form 1. Form collects information on:
- Age: neonate; infant; preschool; school age; adolescent
- Activity observed (select all that apply): history; physical; presentation
- Clinical setting: inpatient; outpatient; emergency department; community
Collect 4 observations of achievement.
- At least 1 neonate or infant
- At least 1 preschool or school age
- At least 1 adolescent
- At least 2 observations by supervisor
- At least 2 observations of a complete encounter that includes history, physical, and presentation
- At least 1 observation of a complete encounter by supervisor
- COM 1.2 Optimize the physical environment for patient and family comfort, dignity, privacy, engagement and safety
- ME 2.2 Elicit an accurate, relevant history
- COM 2.1 Conduct the interview in a patient-centred manner
- ME 2.2 Perform a physical exam that informs the diagnosis
- COM 2.3 Identify other sources of information (e.g., family, medical record) that may assist in the patient’s care
- ME 2.2 Synthesize patient information from the clinical assessment for the purpose of written or oral summary to a supervisor
- P 1.1 Exhibit appropriate professional behaviours