How Part IV Is Actually Graded: the 5 Domains

The single biggest mindset shift for Part IV: it isn't graded on getting the diagnosis right. It's graded on how you run the encounter — across a set of domains. Understand the rubric and you stop optimizing for the wrong thing.

Patient encounters: the five domains

Each of the seven patient stations is scored across these five domains:

1. Patient Evaluations

Obtaining the relevant clinical information — did your history actually surface what the case turned on? Rewarded for asking the right questions, not the most questions.

2. Patient Examination

Accuracy and appropriateness of your exam procedures — running the maneuvers that fit the complaint, correctly, rather than a scattershot exam.

3. Clinical Decision Making & Case Management

Assessing your findings and choosing a course of action — including landing on the correct disposition (treat, co-manage/test, or refer). This is where red-flag recognition lives.

4. Interpersonal & Communication Skills

How effectively you communicate with the patient — rapport, clarity, and a clear report of findings. Candidates lose real points here by being clinically fine but robotic.

5. Documentation

The accuracy and conciseness of your SOAP note — within the 950-character-per-field cap. Prioritized, legible, defensible documentation scores; a rushed data-dump doesn't.

The technique station: eight domains

The technique station is scored across eight domains — every setup is judged on all of them:

• Patient position — positioning the patient correctly for the setup (supine, prone, seated, side-lying).
• Doctor position — your stance and body position relative to the patient.
• Segmental contact point — the correct bony landmark on the target segment, and the right side.
• Doctor's contact point — the part of your hand that contacts the patient (pisiform, hypothenar, thumb, etc.).
• Stabilization hand — your support hand and what it stabilizes.
• Line of drive — the vector / direction of the correction.
• Communication — clearly talking the examiner through each step.
• Professionalism — manner and safety; you set up only, never actually thrust.

Because it's all verbalized, saying the right things precisely — “contact the mammillary process, stabilization at the segment above, line of drive P-to-A and superior” — is the whole game. Fuzzy setups lose points even when your hands would have been fine.

What this means for how you study

• Rehearse the report of findings out loud — communication is a graded domain, not a nicety.
• Commit to a disposition every time — hedging costs you in decision-making.
• Write real SOAP notes under the 950-char cap — documentation is 1 of 5 domains.
• Verbalize technique setups verbatim — the words are the score.

New to the format? Start with The NBCE Part IV Exam, Explained.