Objectives Medical education is a continuum from medical school through residency to unsupervised clinical practice. There has been a movement toward competency???based medical education prompted by the Accreditation Council for Graduate Medical Education ( ACGME ) using milestones to assess competence. While implementation of milestones for residents sets specific standards for transition to internship, there exists a need for the development of competency???based instruments to assess medical students as they progress toward internship. The objective of this study was to develop competency???based milestones for fourth???year medical students completing their emergency medicine ( EM ) clerkships (regardless of whether the students were planning on entering EM ) using a rigorous method to attain validity evidence. Methods A literature review was performed to develop a list of potential milestones. An expert panel, which included a medical student and 23 faculty members (four program directors, 16 clerkship directors, and five assistant deans) from 19 different institutions, came to consensus on these milestones through two rounds of a modified Delphi protocol. The Delphi technique builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Results Of the initial 39 milestones, 12 were removed at the end of round 1 due to low agreement on importance of the milestone or because of redundancy with other milestones. An additional 12 milestones were revised to improve clarity or eliminate redundancy, and one was added based on expert panelists' suggestions. Of the 28 milestones moving to round 2, consensus with a high level of agreement was achieved for 24. These were mapped to the ACGME EM residency milestone competency domains, as well as the Association of American Medical Colleges ( AAMC ) core entrustable professional activities for entering residency to improve content validity. Conclusions This study found consensus support by experts for a list of 24 milestones relevant to the assessment of fourth???year medical student performance by the completion of their EM clerkships. The findings are useful for development of a valid method for assessing medical student performance as students approach residency. Resumen Objetivos La formaci??n m??dica es un continuo que va desde la universidad, pasando por la residencia, hasta la pr??ctica cl??nica no supervisada. Ha habido un movimiento hacia la formaci??n m??dica basada en la adquisici??n de competencias promovido por el Accreditation Council for Graduate Medical Education ( ACGME ) mediante los hitos para evaluar la competencia. Mientras la implementaci??n de los hitos para los residentes establece normas espec??ficas para la transici??n a residente, existe necesidad de desarrollar instrumentos basados en la competencia para evaluar a los estudiantes de medicina seg??n progresan hacia la residencia. El objetivo de este estudio fue desarrollar los hitos basados ??????en competencias para los estudiantes de medicina de cuarto a??o al completar sus pr??cticas cl??nicas en Medicina de Urgencias y Emergencias ( MUE ) (indistintamente si el estudiante planeaba acceder a la MUE ) utilizando un m??todo riguroso para lograr evidencia v??lida. Metodolog??a Se realiz?? una revisi??n de la literatura para desarrollar una lista de hitos potenciales. Un panel de expertos, que incluy?? 23 profesores de la facultad cuyas responsabilidades eran directores de programa (4), directores de pr??cticas cl??nicas (16), vicedecanos (5) y un estudiante de medicina de 19 instituciones diferentes, llegaron a un consenso sobre estos hitos a trav??s de 2 rondas del protocolo de Delphi modificado. La t??cnica Delphi construye un contenido v??lido y es un m??todo aceptado para desarrollar un consenso mediante la obtenci??n de opiniones de expertos a trav??s de m??ltiples rondas de preguntas. Resultados De los 39 hitos iniciales, se eliminaron 12 al final de la primera ronda debido al bajo acuerdo sobre la importancia del hito o debido a su redundancia con otros hitos. Se revisaron 12 hitos adicionales para mejorar la claridad o eliminar la redundancia, y se a??adi?? uno basado en las sugerencias del panel de expertos. De los 28 hitos que llegaron a la segunda ronda, se alcanz?? un consenso con un alto nivel de acuerdo para 24 de los hitos. Estos hitos se esquematizaron a los dominios de competencia de los hitos de la residencia de MUE del ACGME , as?? como a las actividades profesionales recomendadas para acceder a la residencia de la Association of American Medical Colleges ( AAMC ) para mejorar la validez de contenido. Conclusiones Este estudio lleg?? a un consenso apoyado por expertos para una lista de 24 hitos relevantes para evaluar el rendimiento de los estudiantes de medicina de cuarto a??o al finalizar su pr??ctica cl??nica en MUE . Los hallazgos son ??tiles para el desarrollo de un m??todo v??lido para evaluar el rendimiento de los estudiantes de medicina a medida que ??stos se acercan a la residencia.