Medical Residency Log Form
Please complete this form to record your residency training shift. All fields are required for an accurate log entry.
Resident Name
*
First Name
Last Name
Rotation/Service
*
Please Select
Internal Medicine
Surgery
Pediatrics
Emergency Medicine
Obstetrics & Gynecology
Psychiatry
Family Medicine
Anesthesiology
Other
Entry Date
*
-
Month
-
Day
Year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Shift End Time
*
Hour Minutes
AM
PM
AM/PM Option
Training Site/Department
*
Please Select
Main Hospital
Outpatient Clinic
Emergency Department
ICU
Operating Room
Labor & Delivery
Pediatric Ward
Other
Patient Encounter / Worklog Summary
*
Procedures Performed (select all that apply)
Venipuncture
IV Line Placement
Intubation
Central Line Insertion
Lumbar Puncture
Wound Suturing
Chest Tube Placement
Other
Supervising Physician
*
Total Hours Logged
*
Notes / Issues to Follow Up
Submit Log Entry
Should be Empty: