Purpose Given the growing emphasis placed on clerkship performance for residency selection, clinical evaluation and its grading implications are critically important; therefore, the authors conducted this study to determine which evaluation components best predict a clinical honors recommendation across 3 core clerkships. Method Student evaluation data were collected during academic years 2015-2017 from the third-year internal medicine (IM), pediatrics, and surgery clerkships at the University of Alabama at Birmingham School of Medicine. The authors used factor analysis to examine 12 evaluation components (12 items), and they applied multilevel logistic regression to correlate evaluation components with a clinical honors recommendation. Results Of 3,947 completed evaluations, 1,508 (38%) recommended clinical honors. The top item that predicted a clinical honors recommendation was clinical reasoning skills for IM (odds ratio [OR] 2.8; 95% confidence interval [CI], 1.9 to 4.2; P <.001), presentation skills for surgery (OR 2.6; 95% CI, 1.6 to 4.2; P <.001), and knowledge application for pediatrics (OR 4.8; 95% CI, 2.8 to 8.2; P <.001). Students who spent more time with their evaluators were more likely to receive clinical honors (P <.001), and residents were more likely than faculty to recommend clinical honors (P <.001). Of the top 5 evaluation items associated with clinical honors, 4 composed a single factor for all clerkships: clinical reasoning, knowledge application, record keeping, and presentation skills. Conclusions The 4 characteristics that best predicted a clinical honors recommendation in all disciplines (clinical reasoning, knowledge application, record keeping, and presentation skills) correspond with traditional definitions of clinical competence. Structural components, such as contact time with evaluators, also correlated with a clinical honors recommendation. These findings provide empiric insight into the determination of clinical honors and the need for heightened attention to structural components of clerkships and increased scrutiny of evaluation rubrics.