Instructions for the Use of This Log Book
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:
- 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.
- 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).
- 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.
- 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’.
- 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
Details of patients clerked
Date / Intake / Diagnosis / System
e.g. CVS, CNS, etc.
Presentation to Ward Tutor
Initials / Hospital Number / Age / Gender / Tutor / Date / *Comments / Signature
*Comments:
1 - 3=Unsatisfactory / See ‘Supervisor’
4 - 5=Unsatisfactory / Room for Improvement
6=Satisfactory / Meets Expectations
7 - 8 =Satisfactory / Above Expectation
9 - 10=Excellent / Truly Exceptional
Date / Diagnosis / Procedure / System / Tutor’s Signature / Doctor
Procedures Performed
Date / Diagnosis / Procedure / System / Tutor’s Signature / Doctor
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Medical Discharge Summary
Name: Ward:
Age: Gender: DOA: DOD:
Hospital No.: Head of Unit:
Registrar:
Student Intern:
Final Diagnosis / Diagnoses:
History:
Clinical Findings:
Relevant Investigations:
- Blood
- Radiological
- Other
Management and Progress:
Outcome:T.T.O. (Medication: Dose and Route)
Follow-up:
Ward Performance Evaluation (3 WEEK BLOCK)
Criterion / Unsatisfactory(Observed lapses in professional behaviour) / Meets Expectations PASS
(Observed lapses in professional behaviour) / Exceptional
1 – 5 / 6 – 8 / 9 – 10
Clinical Skills / Competence
Score
/ Clumsy + abrupt.
Little concern for patient’s comfort.
Performs careless or incomplete examinations. / Conducts a careful and complete history and physical examination. / Accurately gathers all pertinent data and demonstrates an investigatory and analytic thinking approach to clinical situations.
Has poor understanding of what constitutes a management plan / Able to develop a management plan. / Develops management plan with maturity.
Takes cost, investigations + social aspects into account
Fails to read up on patients / Seeks to update knowledge in interest of current patients’ problems. / Identifies relevant guidelines and practices evidence based medicine.
Ward + Tutorial Performance
Score
/ Attends <90% of ward rounds, seminars, intakes and teaching events.
Sometimes / often arrives late. / Attends >90% of ward rounds, seminars, intakes and other teaching events.
Usually arrives on time / Attends all ward rounds, seminars, intakes and other teaching events.
Always punctual.
Does not prepare for tutorials +/or lacks enthusiasm
Not present in wards outside formal tutorial time. / Actively participates in tutorials.
Spends time constructively in wards / Prepares exceptionally well for tutorials.
Extremely diligent and enthusiastic learner.
Patient Care
Score
/ Shows disrespect to patients and family.
Rude and dismissive or insensitive to patient’s needs. / Caring and respectful towards patients and families.
Appropriately sensitive and responsive to patient’s needs. / Friendly and compassionate to patients.
Displays excellent patient-clinician skills.
Attitude + Behaviour
Score
/ Arrogant + self-centred.
Dresses inappropriately
Dishonest, plagiarises + falsifies records. / Humble + displays loyalty and integrity.
Dresses appropriately.
Adheres to ethical standards – respect, honesty. / Exceptional loyalty + integrity.
Elegant and well groomed.
Exemplary ethical behaviour.
Ward Mark
24 = Pass
32 = 1st Class / Comments (Please ensure you give comments):
Discharge Summaries
Score
/ 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
Long Case
Score
/ 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
Log Book / 1 - 5
(DP Denied) / 6 - 8
(DP Granted) / 9 - 10
Exceptional
Tick whichever is appropriate
Log Book
Score
Maximum Mark: 10 / Poor attendance at intake. / Good attendance at intake. / Excellent attendance at intake.
Inadequate number of cases seen. (>2 patients/intake) / Good number and spread of cases clerked (≥2 patients/intake) and managed. / Exceptional number of cases seen (>3 patients/intake and managed
Inadequate number of procedures witnessed and documented / Witnessed all basic procedures / 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 missedStudent’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