FACULTY OF HEALTH SCIENCES
DEPARTMENT OF INTERNAL MEDICINE
GEMP IV
LOG BOOK
3-WEEK BLOCK
2015
STUDENT NAME:
STUDENT NUMBER:
STUDENT PHONE NUMBER:
WARD/UNIT:
HOSPITAL:
THREE-WEEK BLOCK
INSTRUCTIONS FOR THE USE OF THIS LOG BOOK:
1.
PURPOSE
 The choice of cases that you clerk is up to you – this will help you to ensure that you
see reasonable range of medical problems bearing mind the list of clinical objectives.
 It will enable the Department of Medicine to monitor the type and number of patients
clerked and the procedures witnessed and performed and allow a mark to be
calculated which is reflective of your participation.
 It will be record of the cases presented to ward tutors (consultants and registrars) and
indirectly will be a reflection of your attendance in the ward.
2.
HOW TO COMPLETE THE LOG BOOK
 Only fill in details of patients that you have clerked personally and not those
presented by your colleagues on a ward round.
 If the case is clerked while on intake this should be recorded by placing a tick in the
“intake” column.
 Insert the topic for Problem Based Learning in the relevant section of the booklet and
discuss your involvement with your tutor.
 Ensure that your attendance at intake and post-intake ward round is recorded by
getting the signature of your supervisor (the registrar on call / consultant).
3.
PROCEDURE WITNESSED AND PERFORMED
 Include procedures such as lumbar punctures, bone marrow aspirated, insertion of
chest drains, insertion of central venous lines, paracentesis, peritoneal dialysis,
cardioversion etc. Do not include minor routine procedures such as blood taking and
blood pressure measuring.
 The doctor (tutor)performing or assisting you with the procedure must sign in the
appropriate column record whether the doctor is a consultant (C), registrar (R) or
intern(I)
 There is a separate section for procedure witnessed and procedures performed.
4.
DISCHARGE SUMMARIES
 A minimum of six discharge summaries of patients personally managed by you in the
ward need to be filled in, on the appropriate ‘discharge summary’ forms provided.
 At least two of the six discharge summaries should cover ‘medical emergencies seen
(e.g. Pulmonary oedema, Asthma, Diabetic ketoacidosis, etc.)
 The discharge summaries will be reviewed at the time of presentation of the ‘long
case’.
5.
WHAT TO DO WITH YOUR LOG BOOK

The logbook must be handed in on the last Thursday of your block for assessment
with the consultant in charge of your ward.
ATTENDANCE AT GENERAL MEDICAL INTAKES
DATE
REGISTRAR
SIGNATURE
PIWR
CONSULTANT
SIGNATURE
INTAKE
DATE
DETAILS OF PATIENTS CLERKED
DIAGNOSIS
SYSTEM
E.G. CVS, CNS,
ETC.
*COMMENTS:
1-3
4-5
6
7-8
9 - 10
=
=
=
=
=
*COMMENTS
TUTOR
DATE
GENDER
HOSPITAL
NUMBER
AGE
INITIALS
PRESENTATION TO WARD TUTOR
UNSATISFACTORY / SEE ‘SUPERVISOR’
UNSATISFACTORY / ROOM FOR IMPROVEMENT
SATISFACTORY / MEETS EXPECTATIONS
SATISFACTORY / ABOVE EXPECTATION
EXCELLENT / TRULY EXCEPTIONAL
SIGNATURE
PROCEDURES WITNESSED
DATE
DIAGNOSIS
PROCEDURE
SYSTEM
TUTOR’S
SIGNATURE
DOCTOR
PROCEDURES PERFORMED
DATE
DIAGNOSIS
PROCEDURE
SYSTEM
TUTOR’S
SIGNATURE
DOCTOR
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
A. BLOOD
B. RADIOLOGICAL
C. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
D. BLOOD
E. RADIOLOGICAL
F. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
G. BLOOD
H. RADIOLOGICAL
I.
OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
J. BLOOD
K. RADIOLOGICAL
L. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
M. BLOOD
N. RADIOLOGICAL
O. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
P. BLOOD
Q. RADIOLOGICAL
R. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
S. BLOOD
T. RADIOLOGICAL
U. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
V. BLOOD
W. RADIOLOGICAL
X. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
Y. BLOOD
Z. RADIOLOGICAL
AA. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
BB. BLOOD
CC. RADIOLOGICAL
DD. OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
MEDICAL DISCHARGE SUMMARY
NAME:
AGE:
WARD:
GENDER:
HOSPITAL NO.:
DOA:
HEAD OF UNIT:
REGISTRAR:
STUDENT INTERN:
FINAL DIAGNOSIS / DIAGNOSES:
HISTORY:
CLINICAL FINDINGS:
DOD:
RELEVANT INVESTIGATIONS:
EE. BLOOD
FF. RADIOLOGICAL
GG.
OTHER
MANAGEMENT AND PROGRESS:
OUTCOME:
Follow-up:
T.T.O. (MEDICATION: DOSE AND ROUTE)
WARD PERFORMANCE EVALUATION (3 WEEK BLOCK)
CRITERION
CLINICAL
SKILLS /
COMPETENCE
SCORE
WARD +
TUTORIAL
PERFORMANCE
SCORE
UNSATISFACTORY
EXCEPTIONAL
(Observed lapses in
professional behaviour)
MEETS EXPECTATIONS
PASS
(Observed lapses in
professional behaviour)
1–5
6–8
9 – 10
Clumsy + abrupt.
Little concern for
patient’s comfort.
Performs careless or
incomplete
examinations.
Has poor understanding
of what constitutes a
management plan
Seeks to update
knowledge in interest of
current patients’
problems.
Identifies relevant
guidelines and practices
evidence based
medicine.
Attends <90% of ward
rounds, seminars,
intakes and teaching
events.
Attends >90% of ward
rounds, seminars,
intakes and other
teaching events.
Attends all ward rounds,
seminars, intakes and
other teaching events.
Sometimes / often
arrives late.
Does not prepare for
tutorials +/or lacks
enthusiasm
Usually arrives on time
Always punctual.
Actively participates in
tutorials.
Prepares exceptionally
well for tutorials.
Spends time
constructively in wards
Extremely diligent and
enthusiastic learner.
PATIENT CARE Shows disrespect to
patients and family.
Rude and dismissive or
insensitive to patient’s
needs.
ATTITUDE +
Able to develop a
management plan.
Accurately gathers all
pertinent data and
demonstrates an
investigatory and
analytic thinking
approach to clinical
situations.
Develops management
plan with maturity.
Takes cost,
investigations + social
aspects into account
Fails to read up on
patients
Not present in wards
outside formal tutorial
time.
SCORE
Conducts a careful and
complete history and
physical examination.
Arrogant + self-
Caring and respectful
towards patients and
families.
Friendly and
compassionate to
patients.
Appropriately sensitive
and responsive to
patient’s needs.
Humble + displays
Displays excellent
patient-clinician skills.
Exceptional loyalty +
BEHAVIOUR
SCORE
centred.
loyalty and integrity.
integrity.
Dresses
inappropriately
Dresses appropriately.
Elegant and well
groomed.
Dishonest, plagiarises
+ falsifies records.
Adheres to ethical
standards – respect,
honesty.
Exemplary ethical
behaviour.
WARD MARK
24 = PASS
32 = 1ST CLASS
COMMENTS (PLEASE ENSURE YOU GIVE COMMENTS):
DISCHARGE
SUMMARIES
1 – 3 = UNSATISFACTORY / SEE ‘SUPERVISOR”
4 – 5 = UNSATISFACTORY / ROOM FOR IMPROVEMENT
6
= SATISFACTORY / MEETS EXPECTATIONS
7 – 8 = SATISFACTORY / ABOVE EXPECTATION
0 – 10 = EXCELLENT / TRULY EXCEPTIONAL
Comments
SCORE
LONG CASE
SCORE
LOG BOOK
LOG BOOK
SCORE
Maximum Mark: 10
1 – 3 = UNSATISFACTORY / SEE ‘SUPERVISOR”
4 – 5 = UNSATISFACTORY / ROOM FOR IMPROVEMENT
6
= SATISFACTORY / MEETS EXPECTATIONS
7 – 8 = SATISFACTORY / ABOVE EXPECTATION
0 – 10 = EXCELLENT / TRULY EXCEPTIONAL
Comments
1-5
(DP DENIED)
6-8
(DP GRANTED)
TICK WHICHEVER IS APPROPRIATE
Poor attendance at intake.
Good attendance at
intake.
Inadequate number of
Good number and spread
cases seen. (>2
of cases clerked (≥2
patients/intake)
patients/intake) and
managed.
Inadequate number of
Witnessed all basic
procedures witnessed and
procedures
documented
9 - 10
EXCEPTIONAL
Excellent attendance at
intake.
Exceptional number of
cases seen (>3
patients/intake and
managed
Exceptional umber of
procedures witnessed and
documented.
STUDENT TO COMPLETE SECTION BELOW:
I have read this evaluation and discussed it with block / ward co-ordinator / supervisor.
NO. OF DAYS MISSED
STUDENT’S SIGNATURE:
DATE:
CO-ORDINATOR TO COMPLETE SECTION BELOW:
I am satisfied that the above student has / has not completed the requirements for the
block in medicine.
BLOCK CO-ORDINATOR’S SIGNATURE:
DATE:
©2005
Copyright held by the Department of Internal Medicine
University of the Witwatersrand, Johannesburg