Family Medicine Log
STUDENT: ___________________________________________________
Rotation Site / Preceptor:_________________________________________
Rotation Date: ________________
Rotation Period #:_______________
Clinical faculty review (mid-rotation):__________________________________________
(Clinical faculty signature / Date)
Clinical faculty review (end of rotation):________________________________________
(Clinical faculty signature / Date)
Students are required to complete the Student Log to receive credit for the rotation. The log’s purpose is to ensure that each student is exposed to the
depth and breadth of Family Medicine. The log is divided into two areas: clinical presentations and procedures that the student should perform.
Please document the number of procedures in 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)
Patient Centered Medical Home
Depression
Preventive Health Care
Oral Cavity and Acute Pharyngitis
Diabetes Mellitus
Thoracolumbar Spine (low back)
Coronary Artery Disease (CAD)
Congestive Heart Failure (CHF)
Dyslipidemia
Cigarette Smoking/Tobacco Use
Metabolic Syndrome
Allergy and Asthma
Pulmonary Function Testing/PFT
Common Pulmonary Symptoms
Obstructive Lung Disease
Influenza
Headache (HA)
Gout
Osteoarthritis
Barret’s Esophagitis
Peptic Ulcer Disease (PUD)
GERD
Irritable Bowel Disease (IBD)
Ulcerative Colitis (UC)
Count
Numeric
10
Not
Seen
Comments
Crohn’s
Seborrheic Keratosis
Actinic Keratosis
Basal cell carcinoma
Squamous cell carcinoma
Melenoma
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: Laceration repair
Urinalysis dip and/or microscope
Wet mount prep vaginal
Pap
Pelvic Exam (Speculum and bimanual)
Breast Exam
Prostate Exam
Chest x-ray interpretation
Laceration repair
Punch Biopsy or excision of skin lesion
Subungal hematoma evacuation
Wood’s Lamp Exam
Tick removal
Cryosurgery of skin lesion
Local anesthesia for procedure
Cerumen removal
Foreign body removal from ear/nose/other site
Ambulatory BP measurement
Office EKG
Holter monitoring
Stress testing (office)
PFT’s or Peak flow (office)
DOT Physical
Sports Physical
Male preventive visit
Female preventive visit
Smoking cessation counseling
CLIA Waived Tests
HgbA1c, TSH, Strep, Mono
IV Access/Blood draw
Urine drug screen
OMM:
Cervical
Thoracic
Lumbar
Pelvis/Sacrum
Extremity
Target
minimum
#(Numeric)
Performed
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Not Performed
Comments