Table 1 Matrix for assessment of history taking and clinical reasoning skills (Designed by authors)

Interview

The student asks relevant and sufficient questions that reflect a logical order

The student asks some relevant and necessary questions although he/she does not follow a structured order

The student has problems with structuring relevant questions in the interview

Physical Exam

The student looks for signs in the patient and justifies such search

The student performs an incomplete physical exam or does it in a unstructured manner; does not properly recognize the case’s relevant findings

The student has no ideas on what to look for in the patient’s physical exam

Medical reasoning

The student correlates findings from the physical exam with those from the interview to approach a diagnosis

The student properly correlates some findings of the physical exam with those from the interview, or the student approaches the diagnosis, although he/she does not establish a relation that is consistent with the patient’s signs and symptoms

The student does not evidence the ability to correlate the findings from the physical exam and the interview to approach a diagnosis

Relevance of Additional Exams

The student proposes relevant strategies to acquire additional data that contribute to pinpointing the diagnosis

The student proposes some strategies that are somewhat irrelevant for the acquisition of additional data that contribute to approaching a diagnosis

The student does not propose strategies to a diagnostic approach

Presentation of case

The student presents the clinical case in a logical order and considers all the relevant information

The student presents the clinical case in a slightly unstructured manner, tries to achieve a logical order but fails to do so. Presents both relevant and irrelevant information

The student omits relevant information and does not present the clinical case coherently