MS III CLERKSHIP PATIENT LOGBOOK
DEPARTMENT OF INTERNAL MEDICINE
MS III CLERKSHIP
PATIENT LOG BOOK
TEXAS TECH UNIVERSITY
HEALTH SCIENCES CENTER
In keeping with the accreditation standards of the Liason
Committee on Medical Education, the objectives for clinical
education must include quantified criteria for the types of
patients, the level of student responsibility, and the
appropriate clinical settings needed for the objectives to be
met. Accordingly, to document and permit a review of your
patient experience, a log of all patients evaluated should
be maintained and kept current throughout the clerkship.
Keep this in your white coat pocket. As soon as you get a
patient assigned, enter this in your logbook. List all
patients on whom you have done a complete H&P,
including those seen in the clinic and on elective services.
MEDICINE DEPARTMENT
THIRD YEAR CLERKSHIP
PATIENT LOG BOOK
In the clinic, you may evaluate some patients who are seen
for a relatively “routine” follow-up visit. However, as long
as you have actually seen and examined the patient, an
entry should be made in the logbook.
STUDENT NAME:
_____________________________________
The log entry for each patient should indicate date,
patient’s initials, age, sex, medical record number, and
primary and secondary diagnosis. Primary and secondary
diagnosis should be listed based on the diagnosis groups
as shown in the Master Data Collection Key in this
logbook.
CLERKSHIP STARTING DATE:
_____________________________________
Month/Year
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

The logbook provides a means of monitoring the scope
and diversity of your learning experience. Just before the
mid-rotation review you will be asked to drop off your
logbook at the Clerkship Office long enough to make a
copy of patients seen to date. The logbook is to be turned
in to the Clerkship Office in the Department of Internal
Medicine not later than the last working day of the rotation.
Amarillo
El Paso
Lubbock
NOTE: Log only patients on whom you have personally
done a complete H&P. Log both inpatients and
outpatients that meet these criteria.
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MS III CLERKSHIP PATIENT LOGBOOK
Master Data Collection Key
Patient Logbook Review
Internal Medicine Patient LogBook Diagnosis Groups
Applicable to Patients Seen by Clinical Clerks in Amarillo, El Paso, and Lubbock
The patient logbook will be reviewed and patients seen
summarized by diagnosis groups during the mid
rotation evaluation and at the end of the clerkship in the
table below. This reflects the number of patients seen
by category. The results of this review will be totaled in
the summary chart below. For an explanation of the
disease categories, see the Master Data Collection Key
on the next page.
(Note: Diagnostic Groups are listed in bold followed by abbreviations used on charts)
Cardiovascular CV
Chest Pain (including CAD/MI)
CHF
Arrhythmia
Hypertension
Shock
Thrombophlebitis/DVT
Other (Specify)
Respiratory RESP
COPD (including acute exacerbation)
Asthma
Pneumonia
Pulmonary embolus
Other (specify)
As you go through your clerkship, you should keep this
logbook current and review it frequently with your ward
and clinic attendings and residents. While there are no
specific maximum numbers of patients for each
category, you should have a minimum of at least one
patient in each category and aim for a reasonably
balanced distribution. This will compliment your core
curriculum lectures and facilitate development of a good
Internal Medicine fund of knowledge.
Renal/Genitourinary Disease
RENAL
In general, you should average at least three patients
per week. Thus, you will be able to evaluate 30 or more
patients during a 12-week medicine clerkship.
ARF
CRF
Transplant
Stone
Other (specify)
Infectious Diseases ID
AIDS
Sepsis
UTI/Urosepsis
Cellulitis
Other (specify)
Patient/Diagnosis Summary
Diagnosis Group
Mid-Rotation
Tabulation
Total
End-Rotation
Tabulation
Total
CV
RESP
RENAL
ID
GI
ENDO
RHEUM
HEM/ONC
NEURO
GEN
TOTAL
Gastrointestinal GI
G.I. Bleed (upper or lower)
Diarrhea (any cause)
Liver disease
Pancreatitis
Ascites
Other (specify)
2
Endocrine ENDO
Diabetes
DKA
Thyroid disease
Adrenal disease
Other (specify)
Rheumatology RHEUM
Arthritis
Vasculitis
Lupus/SLE
Other (specify)
Hematology/Oncology
HEM/ONC
Anemia
Thrombocytopenia
Coagulopathy
Other (specify)
Neurology NEURO
Stroke/CVA
Syncope/Dizziness
Epilepsy
Drug overdose
Other (specify)
General areas GEN
Drug problem
Dermatological problem
Psychiatric problem
Alcohol problem
Pain
Testing/Diagnostic evaluation
Other (specify)
MS III CLERKSHIP PATIENT LOGBOOK
PT. INITIALS
AGE/SEX
MED.RECORD#
DATE
PRIMARY
DIAGNOSIS
PT. INITIALS
AGE/SEX
MED.RECORD#
SECONDARY
DIAGNOSIS
3
DATE
PRIMARY
DIAGNOSIS
SECONDARY
DIAGNOSIS
MS III CLERKSHIP PATIENT LOGBOOK
Procedures
Developed by the Clerkship Directors in
Internal Medicine:
The Goals and Objectives for the Internal Medicine Clerkship
call for the development of skills in performing basic clinical
procedures. During your clerkship you should document this
experience for selected key procedures as shown below. It is
recommended that you perform a minimum of 3 and preferably
5 of each of the listed procedures.
Instruction and documentation of completed procedures can
be performed by your resident or intern or as follows:
Venipuncture and blood culture: Phlebotomist
Arterial blood gas: Respiratory therapy technicians
Electrocardiogram: Cardiology/EKG technicians
Nasogastric
intubation
and
urethral
catheterization:
Ward/clinic nurses
Digital rectal examination: ward/clinic resident
Peripheral intravenous catheter insertion: ward resident/nurse
Steve Urban MD, Rush Pierce MD - Amarillo
Robert Kimbrough III, MD - Lubbock
Harry Davis II, MD
- El Paso
Please have the certifying instructor fill in the date with his/her
initials
Procedure
Date/
Initials
Date/
Initials
Date/
Initials
Date/
Initials
Date/
Initials
Venipuncture
Blood culture
Arterial blood gas
Electrocardiogram
Nasogastric
intubation
Urethral
catheterization
Digital rectal
examination
Peripheral
intravenous
catheter insertion
December 4, 2004
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