skills/medical-blueprint-builder/references/assessment-and-tos.md

# Assessment Blueprint and Table of Specifications (TOS)

Use this reference for exam blueprints, MCQ/SBA plans, OSCE plans, residency exams, board-style assessments, and TOS requests.

## 1. Start from outcomes, not question count

Define:
- exam purpose
- learner level
- decisions / competencies being sampled
- content domains
- clinical-task domains
- cognitive demand
- required breadth and safety-critical coverage

Only then allocate items or stations.

## 2. Practical cognitive levels

Use categories that map cleanly to clinical work:
- Recall
- Understand
- Interpret
- Apply
- Clinical reasoning
- Decision-making

A difficult fact-recall item is still recall.

## 3. Clinical-task domains

Depending on the topic, sample:
- recognition
- interpretation
- diagnosis
- prioritized differential
- investigation selection
- severity / risk
- next best management
- complications
- treatment failure
- reassessment
- escalation
- communication / counseling when appropriate

## 4. Performance level

Use Miller pragmatically:
- Knows
- Knows how
- Shows how
- Does

Written SBA/MCQ can assess knowledge, interpretation, reasoning, and decisions at a "knows how" level. They do not directly demonstrate bedside, procedural, or workplace performance.

Use OSCE/simulation for "shows how" and workplace-based methods for "does" when those levels matter.

## 5. Proposed weighting

If no official blueprint is supplied, label percentages as **Proposed weighting** or **Suggested emphasis**.

Base proposals on:
- frequency
- clinical danger
- decision impact
- role relevance
- curriculum exposure
- feasibility of assessment

Avoid false precision. Explain the rationale briefly.

## 6. TOS template

| Content domain | Key outcomes / decisions | Priority | Cognitive / clinical task | Proposed weight | Item / station count | Format |
|---|---|---|---|---:|---:|---|

Add totals and confirm that weighting and counts are internally consistent.

## 7. Item-format matching

Use:
- SBA/MCQ clinical vignette for interpretation, application, reasoning, next-step decisions
- key-feature questions for critical decision points
- OSCE / simulation for demonstrated performance
- workplace-based assessment for real clinical performance

Do not test a high-level competency only with isolated factual recall.

## 8. Safety sampling

Ensure the assessment samples:
- instability / red flags
- dangerous mimics
- contraindications or critical errors
- treatment failure
- escalation triggers
- reassessment

## 9. Quality checks

Before finalizing:
- outcomes are actually sampled
- low-priority trivia does not dominate
- clinical reasoning is represented
- proposed weights are labeled honestly
- item format matches competency level
- safety-critical content is included
- counts and percentages reconcile