TTD 1: Performing and presenting a basic history and physical examination

Key Features

• 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.

Assessment Plan

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

CanMEDS milestones

1. COM 1.2 Optimize the physical environment for patient and family comfort, dignity, privacy, engagement and safety
2. ME 2.2 Elicit an accurate, relevant history
3. COM 2.1 Conduct the interview in a patient-centred manner
4. ME 2.2 Perform a physical exam that informs the diagnosis
5. COM 2.3 Identify other sources of information (e.g., family, medical record) that may assist in the patient’s care
6. ME 2.2 Synthesize patient information from the clinical assessment for the purpose of written or oral summary to a supervisor
7. P 1.1 Exhibit appropriate professional behaviours