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Rule 1: Each item should focus on an important concept or testing point.
As a healthcare provider and educator assisting in the development of an examination, you may be asked to write
items to assess test-taker knowledge of a particular domain. What do you want the test-taker to know or demon-
strate? e topic of the item usually results from the blueprint, which is the outline of the major topics to be covered
on the examination. For instance, if an examination is developed to assess knowledge of the cardiovascular system,
the blueprint might have two dimensions: 1) disease-based (e.g., hypertension, ischemic heart disease, systolic heart
failure), and 2) task-based (e.g., assessment of foundational science principles, diagnosis, history, prognosis). e
blueprint would likely include items along both dimensions, and might call for six items on hypertension, four on
systolic heart failure, two on diastolic heart failure, ten on ischemic heart disease, and so on. Along the task dimen-
sion there might be a similar distribution of topics. A clear and comprehensive blueprint or other set of test specica-
tions should always be available so that item writers can stay focused on the important topics and write sucient
numbers of items for each topic.
Rule 2: Each item should assess application of knowledge, not recall of an isolated fact.
e rst step in writing an item is to develop an appropriate stimulus to introduce the topic, such as a clinical or ex-
perimental vignette, to provide context to the question being asked. If there is no such stimulus, the resulting item
will generally be assessing knowledge recall. ese types of items make it dicult for the educator to assess any
higher level within Bloom’s taxonomy, such as “application of knowledge.” For instance, an item consisting of one sen-
tence, “Which of the following medications is used to decrease preload in systolic heart failure?” would assess only
the recall on the mechanisms of action of a list of pharmacotherapeutic agents.
It can be helpful to use actual cases previously encountered as a source of ideas for items and vignettes. However, you
should avoid relying on or adhering too closely to actual patient cases because these oen have atypical features that
may divert from a typical or representative case and lead to confusion. Additionally, in some instances, such as the
example with systolic heart failure, there will be an additional step that you must keep in mind: you should consider
the underlying cause of the heart failure. Patient demographics, past medical history, and other factors will dier de-
pending on the etiology of the condition. Patients with systolic heart failure from a viral cardiomyopathy versus from
ischemic heart disease may have dierent demographics and a dierent history; e.g., a younger patient with a viral ill-
ness preceding the onset of heart failure symptoms as compared to an older patient with risk factors for ischemic
heart disease.
Chapter 5: Basic Rules for Writing One-Best-Answer Items