NP students: you need to log every patient you see in this “Patient Log” Student: Date: Course: Clinical Faculty: Preceptor: Patient number: 1 Category Item Value Tally Client Information Site Inpatient hospital ICU Office Nursing home Subacute Inpatient Long Term Care Age < 1 year 1–3 years 4–5 years 6–9 years 10–12 years 13–18 years 19–21 years 22–64 years 65+ years Sex Male Female Visit Information Student Level of Function Intense supervision – Level 1 Some Supervision – Level 2 Joint Care – Level 3 Mostly Independent – Level 4 Independent – Level 5 Practice Management Level of visit/phys. exam New acute visit – 99203 Acute office – 99213 Chronic office – 99212 New hospital – 99222 Subsequent hospital – 99232 New subacute – 0194 Subsequent subacute – 0193 New ICU – 99292 Subsequent ICU – 99291 ER – 99284 OB – 99213 Post Partum – 99212 Delivery – 59409 Health supervision for newborn under 8 days old – V20.31 Health supervision for newborns 8 to 28 days old – V20.32 Routine infant or child health check – V20.2 Infant (younger than 1 year) well visit – 99381 Early childhood (age 1–4 years) well visit – 99382 Late childhood (age 5–11 years) well visit – 99383 Adolescent (age 12–17 years) well visit – 99384 Adult (18 years or older) well visit – 99385 Diagnosis 1 2 3 4 Procedure 1 obs asst perf N/A 2 obs asst perf N/A 3 obs asst perf N/A 4 obs asst perf N/A Student treatment plan and notes IV Medication 1 managed monitored Not applicable 2 managed monitored Not applicable 3 managed monitored Not applicable 4 managed monitored Not applicable 5 managed monitored Not applicable
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