Patient Encounter Log
Purpose
Students must maintain a daily electronic Patient Encounter Log (PEL) documenting required clinical experiences during clinical rotations. The PEL is based on the required clinical experiences (“must see" list) developed by faculty and included in the clerkship syllabus. The PEL is accessed through the SGU Portal.
The PEL serves several purposes. It helps students document their clinical experiences, supports self-directed learning, complements—but does not replace—independent study, provides the School with a means of monitoring the breadth of students' clinical experiences, and serves as a component of clerkship evaluation.
Required Documentation
For each patient encounter, students must complete all required fields in the PEL, including rotation, hospital, date, chief complaint, primary diagnosis, secondary diagnoses, clinical setting, related Communication Skills modules, level of responsibility, and category of illness.
The PEL also includes an upload feature and an optional comment section. Students use the upload feature to submit required case write-ups and other required forms, such as the Interim Feedback Form and the Preventive Family Medicine Visit Form.
Students may use the optional comment section to document relevant cultural issues, SOAP note information, procedures, or medical literature related to the patient encounter.
Patient Confidentiality
Students must remain HIPAA compliant by excluding patient identifiers, such as names, initials, dates of birth, medical record numbers, photographs, or other identifying information.
Definition of a Patient Encounter
Students should log only encounters involving real patients. Simulated patients, case presentations, videos, grand rounds, written clinical vignettes, and similar educational activities should not be logged. Although these activities are valuable for clinical education, USMLE Step 2 preparation, and postgraduate training, they do not constitute patient encounters for logging purposes.
Patient encounters may occur in various clinical settings and involve different levels of student responsibility. The most meaningful encounters include student participation in the initial history and physical examination, diagnostic decision-making, and management. Students should also log less involved encounters, such as bedside presentations by another clinician, and patient experiences in the operating room or delivery room.
Required Clinical Experiences
The required symptoms (chief complaints) and diagnoses identify the clinical experiences students are expected to encounter during the clinical curriculum. Students should have exposure to approximately 50 symptoms and 180 diagnostic entities. The PEL provides the lists alphabetically and by specialty for convenience.
For each patient encounter, students are expected to understand the primary and secondary diagnoses and complete additional reading, including relevant review or research articles. Where appropriate, students may also complete and log a related Communication Skills module.
If students do not encounter a required clinical entity during a clerkship or Family Medicine rotation, they should complete the corresponding virtual encounter using the links provided in the learning management system and record it in the PEL. Students are also expected to seek these required clinical encounters during the fourth year.
Students are expected to read broadly throughout the clinical years, including about patients they encounter and those they do not.
Maintaining the PEL
Students are expected to maintain the PEL throughout the clinical curriculum and update entries as new clinical information becomes available, such as additional diagnoses, changes in clinical setting, or disease progression. The PEL is designed to encourage students to document the complexity of patient care, including multiple diagnoses, psychosocial issues, and other factors that influence patient management and outcomes.
If a diagnosis is not listed, students should select the closest related diagnosis. Standardized diagnoses allow the School to monitor the breadth of clinical experiences across affiliated hospitals.
Using the PEL
The PEL link is located in the SOM Clinical Studies section of the SGU Portal. Selecting the PEL link directs students to the sign-in page and Main Menu.
From the Main Menu, students may:
• Enter a new patient encounter
• Review or edit existing encounter logs
• Print selected encounter logs
To enter a new patient encounter, students select Enter a New Patient Encounter, complete all required fields using the available drop-down menus, and select Submit My Log when finished.
To review or edit logs, students select Review or Edit Encounter Logs, select the log to review or revise, and use Edit This Log to make changes.
To print logs, students select Print Your Logs, select the logs to be printed, select Print Selected Logs, and then select Print This Page. Students should bring a printed copy of the PEL to the mid-core evaluation.