OMM Procedure Log
STUDENT: ____________________________________________________
Rotation Site / Preceptor: ___________________________________(MD/DO)
Rotation Date: ________________
Rotation Period #:_______________
Clinical faculty (end of rotation):________________________________________
(Clinical faculty signature / Date)
Students are required to complete the OMM Procedure Log to receive credit for the rotation. The purpose of this log is to document OMM techniques
performed in the clinical setting. The log is divided into two areas: clinical presentations and procedures. Please document the number of clinical
presentations you encountered and document the OMM which you performed.
For each clinical presentation/procedure listed below, record:
a) The number seen. *Remember, a patient may have more than one diagnosis or procedure.
b) If not seen, please mark appropriate column.
Clinical Presentation
Example: Headache (HA)
Headache(HA)
TMJ
Neck Pain
Count
Numeric
Not
Seen
# Of Patients
Treated w/OMM
Comments
10
Thoracic or Rib Pain
Low Back Pain
Upper Extremity Pain
Lower Extremity Pain
Herniated Disc
Neuritis
Plexopathy
Fibromyalgia/Chronic Pain)
Gait Disorder
Allergy
Upper Respiratory Infection
Lower respiratory Infection
Influenza
Asthma
Chronic Obstructive Lung Disease
Congestive Heart Failure (CHF)
Upper Abdominal Disorder(PUD etc.)
Lower Abdominal Disorder (IBS etc.)
Gout
Osteoarthritis
Rheumatoid Arthritis
For each procedure listed below, record either:
a) The number of procedures performed. (The target minimum is for your reference, but please record the total number of procedures performed.)
b) If procedure was not performed, please mark appropriate column.
Procedure
Example: OMM
OMM: Areas Treated
Cervical
Thoracic
Lumbar
Pelvis/Sacrum
Extremity
Ribs
OMM Techniques Used:
ME
Indirect
HVLA
Lymphatic Pump
Rib Raising
Soft Tissue
FPR
Counterstain
Cranial
Galbreths Technique
Paraspinal Inhibition
Pedal Pump
Myofacial Release(Indirect or Direct)
Suboccipital Release
Spencer Technique
Sacral Rocking
Other
#(Numeric)
Performed
1
Observed/Asst
Faculty
yes
Comments