SIUSOM Year Two Logbook

Name:

Date:

Patient:

Age: Race: Gender:

Setting:

Note: The next two fields (Mentor name and hours) only need to be filled in once per visit.

Mentor:

Hours:

Diagnosis 1:

Organ System
Diagnosis 1

Diagnosis 2:

Organ System
Diagnosis 2

Diagnosis 3:

Organ System
Diagnosis 3

Procedure:
(to select more than one item, click on
each item while holding down the
<control> key)

Procedure Role:

Clinical Summary/ Significant Findings:

Problem List: