This system allows us to collect information on the types of patient encounters you experience while on the Neuro/Neurosurgery Junior Clerkship. Please fill in the information below and hit "Submit" for each NEW patient you see. If you subsequently do a procedure on this patient, or if the patient manifests a new Diagnostic Category, then you can fill out a new form on the patient (marking that you have reported the patient before), but don't routinely fill out multiple forms on the same patient..

                          Last Name:   (add a comma and initials if more than one person in the class with the same last name)
                              Password:
    Date of Patient Encounter: (mm/dd/yyyy)
Reported this patient before: (Only check this box if you have filled out one of these forms on this patient before)
                                Location:
                                   Setting:

Patient Information: Age: Gender: Ethnicity:

All Information above this line must be filled in for each patient encounter reported.
Only fill out the items below that are appropriate

Type of Encounter:

Diagnostic Category1: (Category 1 is the main category. Only
Diagnostic Category2: select the others if the patient manifests
Diagnostic Category3: more than one major category)
Diagnostic Category4:

Procedure:

Please click the button in front of the Educational Competency that you feel this patient encounter addressed (click all that apply):
     Medical Knowledge
     Patient Care
     Professionalism
     Interpersonal and Communication Skills
     Medical Informatics
     Population Health and Preventive Medicine
     Practice-Based and Systems-Based Medical Care

Comments:
(Please do not put any patient identifying information in this comment)