Pediatrics Patient Encounter Elective Logbook

Student Name:
Elective

If Extramural or IDE, enter identifying information here:
Class:
Elective End Week:
Date Patient Seen:   
Patient's Age:
Patient's Race:
Patient's Gender:    
Location: 
Discipline:
Primary Diagnosis: 

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Procedure:

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Procedure Role:  

Management Plan:

Problem List:

Notes/Comments:

  

Jean Afflerbach, Web Master
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Revised: November 06, 2009