RG Appendix 1: A toolkit of workplace-based assessment forms

Last updated: October 2009

This appendix presents sample forms for assessing IMG performance in the workplace, for the following assessment methods:

Mini-Clinical Evaluation Exercise (Mini-CEX) form.

Direct Observation of Procedural Skills (DOPS) form.

Case-based Discussion (CBD) form

Multisource feedback (360 degree assessment) forms:

Co-worker questionnaire (page 1)

Co-worker questionnaire (page 2)

Medical colleague questionnaire (page 1)

Medical colleague questionnaire (page 2)

Patient questionnaire

Self questionnaire (page 1)

Self questionnaire (page 2)

Assessment forms for structured supervision assessment are available via the CPMEC website.

Descriptors of Competencies Assessed during the Mini-CEX

  1. Medical Interviewing and Communication Skills:
  • Facilitates patient’s telling of story; effectively listens and uses questions/directions to obtain accurate, adequate information needed; responds appropriately to affect non-verbal cues.
  1. Physical Examination Skills:
  • Follows efficient, logical sequence; balances screening/diagnostic steps for problem; informs patient; sensitive to patient’s comfort, modesty.
  1. Professionalism/Humanistic Qualities:
  • Shows respect, compassion, empathy, establishes trust, attends to patient’s needs of comfort, modesty, confidentiality, modesty.
  1. Counselling Skills:
  • Explains rationale for test/treatment, obtains patient’s consent, educates/counsels regarding management.
  1. Clinical Judgment:
  • Selectively orders/performs appropriate diagnostic studies, considers risks and benefits, arrives at an accurate diagnosis or differential diagnosis and identifies effective management strategies.
  1. Organisation/Efficiency:
  • Prioritises; is timely and succinct.

Overall Clinical Competence:

Demonstrates judgment, synthesis, caring, effectiveness and efficiency.


Posted in WBA resource guide.