CMD-108-17-00

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF MEDICINE

CLINICAL CLERKSHIP
SUMMARY OF LEARNING EXPERIENCES

STUDENT NO: _________________ HOSPITAL AND DEPARTMENT:____________________

NAME OF CLINICAL CLERK:______________________ MONTH OF ROTATION:__________________________

I. Written Requirements

Tick the appropriate Box

In-Patient

Discharge
Summary
Progress
Physician

History/

Abstract

Protocol
Clinical
Date

Death
Index

Notes
Drug
Diagnosis In-Charge &

OPD

PE
No. Name of Patient Seen/
Signature
Admitted

(For more than 10 patients please attach another sheet)

 CMD-108-17-00

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF MEDICINE

CLINICAL CLERKSHIP
SUMMARY OF LEARNING EXPERIENCES

STUDENT NO: _________________ HOSPITAL AND DEPARTMENT:____________________

NAME OF CLINICAL CLERK:______________________ MONTH OF ROTATION:__________________________

II. Skills / Related Learning Experience

Physician
No. Name of Patient Procedure Observed Performed In-Charge &
Signature

(For more than 10 patients please attach another sheet)

 OUR LADY OF FATIMA UNIVERSITY CMD-108-17-00
COLLEGE OF MEDICINE

CLINICAL CLERKSHIP
SUMMARY OF LEARNING EXPERIENCES

STUDENT NO: _________________ HOSPITAL AND DEPARTMENT:____________________

NAME OF CLINICAL CLERK:______________________ MONTH OF ROTATION:__________________________

III. Other Requirements

E.g. (Oral Report, Journal Presentation, Family Case, Committee Activities)

No. Date Activity Physician

In-Charge &
Signature

(For more than 10 patients please attach another sheet)