EXTERNSHIP PROGRAM

PATIENT LOG FORM

2013-2014

Fields marked with * are required.


Name of Rotation*
Attending Doctor*
Extern*
Graduation Year*
Extern e-mail address* (UMSL e-mail SSO required)
Term*

Patient Data From:

To:


AGE	# patients
0-18
19-39
40-64
65 -

Note: Please include the number of individual patient observations and patients screened in these totals above. The table above should contain the total number of patients that you have seen. These data are then detailed in the table at the right.>>>>>>>>>

The totals in the 2 tables must be the same.

	PATIENT	ENCOUNTER	TYPE

	COMP	FU/VT	OBSERVE/
			CO-MAN

PC (patients older than 18)

CL

PEDS (patients18 and younger)/BV Put VT in FU column

LV

DISEASE (enter EHMS patients)

SCREENING (enter in OBSERV column)

NEIGHBORHOOD SITES

Individual Sites	# Patients	Individual Sites	# Patients	Individual Sites	# Patients
Family Care HC		Grace Hill HC		CHIPS
StL Society Blind		People's HC		Myrtle Davis HC
Alexian Bros		Delmar Gardens		SLU Optometry
TLC Laser Center		MEC SLAAA		MEC Peds
University Eye Center		Optometric Center		Harvester Eye Care
East St. Louis Eye Center		Pepose Vision		FOR FUTURE USE

PRIMARY DIAGNOSES- max 3/patient

Refractive error 367

Eyelid/lacrimal 373/375

Conjunctivitis 372

Cornea 371

Iris/ciliary body 364

Glaucoma 365

Lens/vitreous 366/379

Retina/choroid 361/363

Oculomotor 378

Globe/orbit 360

Neuro-ophth 377

TREATMENTS -max 3/patient

SPEC

CL

VT

LV

Rx MEDS

OTC MEDS

LASER(pre&post testing)

INJECTABLES

REFERRAL

OTHER

Submit your case reports through Mygateway!

Questions? e-mail Alex Harris O.D., Director of Externship Programs (314-516-5603)
Questions? e-mail Yolanda Flanigan, Support Staff for Externship Programs (314-516-5606)