CANCER INSTITUTE (WIA), Adyar, Chennai –

600020
Tamil Nadu, India

LOGBOOK
DNB Palliative Medicine

Department of Anaesthesia, Pain, and Palliative

Care
Name of the P.G. Student:

Name of the Faculty members:

Department of Anaesthesia, Pain, and Palliative

Care,
Cancer Institute (WIA),
Adyar, Chennai- 600020
Tamil Nadu, India.
 Cancer Institute (WIA), Adyar,
Chennai – 600020
Department of Anaesthesia, Pain,
and Palliative Care.

CERTIFICATE

This is to certify that Dr.___________________

was registered as Diplomate of National Board (DNB) in the
subject of Palliative Medicine for the session 20__ to 20__. The
procedures and the academic activities recorded in the logbook
have been checked, authenticated and are as per the institute
records. They have been carried out under the guidance of the
faculty members of the Department of Anaesthesia, Pain, and
Palliative care.

Course Director Head of the Department Dean

 DISSERTATION DETAILS
TITLE
___________________________________________________________________
_____
___________________________________________________________________
_______
______________________________________________________

__________________________Stipulated date of submission________

Date of approval by Institutional Review Board/Ethics committee:

________________________________________

Date of submission of completed dissertation:

____________________________________________________

Name of PG Teacher:
_________________________________________________________

Signature of PG teacher:
_________________________________________________________

Dated__________________________
 PERSONAL DETAILS

PHOTO
1.Full Name (Surname, first name, middle name):
______________________________________________

2.Date of Birth (DD/MM/YY):

_________________________________________________________

3.Age:
_________________________________________________________

4.Permanent Address & telephone number:

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_______

5.Local address and telephone /mobile:

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_______

6.E-mail id:
_________________________________________________________

7.MBBS Degree:
a. Year of passing:
_________________________________________________________
b. College:
___________________________________________________________________
_______________________________________________

c. University:
___________________________________________________________________
_______________________________________________

d. Distinction/Prizes/Medals/Scholarships etc.,
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_________________

8.Internship:
a. Month/year of beginning:
_________________________________________________________

b. Month/year of completion:
_________________________________________________________

c. College & Hospital:

_________________________________________________________

9.Previous Experience (Give details):

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_______
10.Medical Council Registration No:
_________________________________________________________

11.Name of PG teacher:
_________________________________________________________

12.Month & year of joining the course:

_________________________________________________________

13.Month & year of appearing for the degree/diploma examination:

_________________________________________________________

14.Special interest/Extracurricular Activities:

 CHRONOLOGICAL RECORD OF RESIDENCY TRAINING

FROM TO SPECIALITY/SUB- UNIT IN INSTITUTION

SPECIALITY CHARGE
 FIRST YEAR RESIDENCY
(PALLIATIVE MEDICINE CORE TRAINING)
END OF POSTING ASSESSMENT

SL PARTICULARS QUARTER.1 QUARTER.2 QUARTER.3 QUARTER.4

NO
From- To
1 Punctuality and Reliability (5%)
2 Dependability (5%)
3 Quality of Work (10%)
4 Bedside manners (10%)
5 Patient Interaction/
Counselling (5%)
6 Case workup (10%)
7 Systematic reporting/
Presentation (5%)
8 Case follow-up (5%)
9 Documentation (5%)
10 Team work/ Interpersonal skills
(5%)
11 Attire and self-presentation
(5%)
12 Knowledge and preparedness
(10%)
13 Application of knowledge (5%)
14 Procedure skill (5%)
15 Teaching initiatives/ skills (5%)
16 Research interest/ initiatives
(5%)
NET SCORE (100%)

Signature and Seal of Head of

Department/ Unit Head with
Date

5 Outstanding (80% and above)

4 Excellent (70-19%)

3 Good (60-69%)

2 Average (50-59%)

1 Below average (less than 50%)

 SECOND YEAR RESIDENCY
(NON- CORE TRAINING)
END OF POSTING ASSESSMENT

SL PARTICULARS
NO
From- To
1 Punctuality and Reliability (5%)
2 Dependability (5%)
3 Quality of Work (10%)
4 Bedside manners (10%)
5 Patient Interaction/
Counselling (5%)
6 Case workup (10%)
7 Systematic reporting/
Presentation (5%)
8 Case follow-up (5%)
9 Documentation (5%)
10 Team work/ Interpersonal skills
(5%)
11 Attire and self-presentation
(5%)
12 Knowledge and preparedness
(10%)
13 Application of knowledge (5%)
14 Procedure skill (5%)
15 Teaching initiatives/ skills (5%)
16 Research interest/ initiatives
(5%)
NET SCORE (100%)

Signature and Seal of Head of

Department/ Unit Head with
Date

5 Outstanding (80% and above)

4 Excellent (70-19%)

3 Good (60-69%)

2 Average (50-59%)

1 Below average (less than 50%)

 SECOND YEAR RESIDENCY
(NON- CORE TRAINING)
END OF POSTING ASSESSMENT

SL PARTICULARS
NO
From- To
1 Punctuality and Reliability (5%)
2 Dependability (5%)
3 Quality of Work (10%)
4 Bedside manners (10%)
5 Patient Interaction/
Counselling (5%)
6 Case workup (10%)
7 Systematic reporting/
Presentation (5%)
8 Case follow-up (5%)
9 Documentation (5%)
10 Teamwork/ Interpersonal skills
(5%)
11 Attire and self-presentation
(5%)
12 Knowledge and preparedness
(10%)
13 Application of knowledge (5%)
14 Procedure skill (5%)
15 Teaching initiatives/ skills (5%)
16 Research interest/ initiatives
(5%)
NET SCORE (100%)

Signature and Seal of Head of

Department/ Unit Head with
Date

5 Outstanding (80% and above)

4 Excellent (70-19%)

3 Good (60-69%)

2 Average (50-59%)

1 Below average (less than 50%)

 SECOND YEAR RESIDENCY
(NON- CORE TRAINING)
END OF POSTING ASSESSMENT

SL PARTICULARS
NO
From- To
1 Punctuality and Reliability (5%)
2 Dependability (5%)
3 Quality of Work (10%)
4 Bedside manners (10%)
5 Patient Interaction/
Counselling (5%)
6 Case workup (10%)
7 Systematic reporting/
Presentation (5%)
8 Case follow-up (5%)
9 Documentation (5%)
10 Team work/ Interpersonal skills
(5%)
11 Attire and self-presentation
(5%)
12 Knowledge and preparedness
(10%)
13 Application of knowledge (5%)
14 Procedure skill (5%)
15 Teaching initiatives/ skills (5%)
16 Research interest/ initiatives
(5%)
NET SCORE (100%)

Signature and Seal of Head of

Department/ Unit Head with
Date

5 Outstanding (80% and above)

4 Excellent (70-19%)

3 Good (60-69%)

2 Average (50-59%)

1 Below average (less than 50%)

 SECOND YEAR RESIDENCY
(NON- CORE TRAINING)
END OF POSTING ASSESSMENT

SL PARTICULARS
NO
From- To
1 Punctuality and Reliability (5%)
2 Dependability (5%)
3 Quality of Work (10%)
4 Bedside manners (10%)
5 Patient Interaction/
Counselling (5%)
6 Case workup (10%)
7 Systematic reporting/
Presentation (5%)
8 Case follow-up (5%)
9 Documentation (5%)
10 Team work/ Interpersonal skills
(5%)
11 Attire and self-presentation
(5%)
12 Knowledge and preparedness
(10%)
13 Application of knowledge (5%)
14 Procedure skill (5%)
15 Teaching initiatives/ skills (5%)
16 Research interest/ initiatives
(5%)
NET SCORE (100%)

Signature and Seal of Head of

Department/ Unit Head with
Date

5 Outstanding (80% and above)

4 Excellent (70-19%)

3 Good (60-69%)

2 Average (50-59%)

1 Below average (less than 50%)

 THIRD YEAR RESIDENCY
(PALLIATIVE MEDICINE CORE TRAINING)
END OF POSTING ASSESSMENT

SL PARTICULARS QUARTER.1 QUARTER.2 QUARTER.3 QUARTER.4

NO
From- To
1 Punctuality and Reliability (5%)
2 Dependability (5%)
3 Quality of Work (10%)
4 Bedside manners (10%)
5 Patient Interaction/
Counselling (5%)
6 Case workup (10%)
7 Systematic reporting/
Presentation (5%)
8 Case follow-up (5%)
9 Documentation (5%)
10 Team work/ Interpersonal skills
(5%)
11 Attire and self-presentation
(5%)
12 Knowledge and preparedness
(10%)
13 Application of knowledge (5%)
14 Procedure skill (5%)
15 Teaching initiatives/ skills (5%)
16 Research interest/ initiatives
(5%)
NET SCORE (100%)

Signature and Seal of Head of

Department/ Unit Head with
Date

5 Outstanding (80% and above)

4 Excellent (70-19%)

3 Good (60-69%)

2 Average (50-59%)

1 Below average (less than 50%)

 ACADEMIC PRESENTATION ASSESSMENT
Journal Article Presentation

Topic

Date
1. Article relevance (5%)
2. Article Authenticity (5%)
3. Explained study context and
background (5%)
4. Understood study
methodology (10%)
5. Understood statistical
analysis (5%)
6. Critically analysed the results
(10%)
7. Understood the study
limitations (10%)
8. Able to conclude (10%)
9. Cross references examined
(5%)
10. Answers audience questions
(10%)
11. Audience engagement (5%)
12. Presentation style (5%)
13. Clarity of presentation (5%)
14. Effectiveness (5%)
15. Audio-visual aids (5%)
Net score (100%)
Signature of the moderator

Grading system

5 Outstanding (80% and above)

4 Excellent (70-79%)
3 Good (60-69%)
2 Average (50-59%)
1 Below average (40-49%)
 Subject Seminar Presentation

Topic

Date

1. Comprehensive
presentation (10%)
2. Flow of presentation (5%)
3. Covers all the specific
subtopics (10%)
4. Depth of knowledge (5%)
5. Content authenticity (5%)
6. Evidence of extensive
search/research (10%)
7. Recent advances relevant
to seminar topic (5%)
8. Summarizes key learning
points (10%)
9. Time management (5%)
10. Answers audience
questions (5%)
11. Audience engagement
(10%)
12. Presentation style (5%)
13. Clarity of presentation
(5%)
14. Effectiveness (5%)
15. Audio- visual aids (5%)
Net score (100%)
Signature of the
moderator

Grading system

5 Outstanding (80% and above)

4 Excellent (70-79%)
3 Good (60-69%)
2 Average (50-59%)
1 Below average (40-49%)
 Clinical case presentation

Topic

Date

1. Comprehensive history
(10%)
2. All relevant points elicited
(10%)
3. Logical order of
presentation (5%)
4. Clarity of presentation (5%)
5. Non-physical history elicited
comprehensively (5%)
6. General and systematic
examinations carried out
logically (10%)
7. All physical signs elicited
(10%)
8. Arrived at diagnosis
corroborating H & E (10%)
9. Differential diagnosis
provided (5%)
10. Able to defend the
diagnosis (5%)
11. Able to plan further
management (5%)
12. Able to answer questions
(5%)
13. Subject knowledge (5%)
14. Effectiveness (5%)
15. Time management (5%)
Net score (100%)
Signature of the
moderator

Grading system

5 Outstanding (80% and above)

4 Excellent (70-79%)
3 Good (60-69%)
2 Average (50-59%)
1 Below average (40-49%)
 FORMATIVE ASSESSMENT OF THESIS PROGRESS
Broad evaluation of thesis progress

Topic

Guide

Progress 12 months 18 months 24 months 30 months

(submission)
Satisfactory/Not
satisfactory
Comments

Signature of the
Guide

Thesis Progress 12 months after joining PG Course

Sl.no. Particulars Grade
1 Interest shown in selecting topic/ research question.
2 Appropriate review of literature
3 Discussion with guide and other faculty
4 Concept notes prepared.
Net Score

Signature of the Guide

Grading System
5 Outstanding (80% and above)
4 Excellent (70%-79%)
3 Good (60-69%)
2 Average (50-59%)
1 Below Average (40-49%)
 Thesis progress 18 months after joining PG course
Sl.No Particulars Grade
1 Thesis protocol is complete
2 Clinical Record Form and Informed Consent is ready
3 Ethical board permission sought
4 Active patient recruitment has begun
Net Score

Signature of the Guide

Thesis progress 24 months after joining PG course

Sl.No Particulars Grade
1 Active recruitment of study participants
2 Progress in the desired direction
3 Interim analysis of the results
4 Regular discussion with the guide
Net Score

Signature of the Guide

Thesis progress 30 months after joining PG course.

Sl.No Particulars Grade
1 Analysis, interpretation of results is complete
2 Discussion and conclusion are complete
3 Findings of the research presented in the department and
approved
4 Quality of the study and output
Net Score

Signature of the Guide

Grading System
5 Outstanding (80% and above)
4 Excellent (70%-79%)
3 Good (60-69%)
2 Average (50-59%)
1 Below Average (40-49%)
 Record of (interesting) cases
Posting:
Outdoor patients/Indoor patients/ Emergency and hospice

Date Patient ID Setting Diagnosis Care issues

____________________
Faculty’s signature
 Log of patient related activities
Date Counseling/Home visit/Bereavement/Support group Care issues
meetings/DMGs addressed

___________________
Faculty’s signature
 Record of procedures
Date Patient ID Setting Diagnosis Procedures

___________________
Faculty’s signature
 Log of academic activities attended
Courses and educational meetings attended
Date Guest lecture/ CMEs/Conferences/Events/Courses/Teaching
activities/Symposia/Workshops

____________________
Faculty’s signature
 Academic Activities – CI Faculty
Sl.No Date Topic Presenter Moderator
 Academic Activities – CI Common PG Class
Sl.No Date Topic Presenter
 Academic Activities – NBEMS lectures
Sl.No Date Topic Presenter
 Academic Activities – IAPC lectures
Sl.No Date Topic Presenter Moderator