BACHELOR OF PHYSIOTHERAPY

INTERN’S LOG BOOK

Intern’s Full name :
Recent passport
size photograph of
Signature : _________________ intern

Permanent address :

Contact Number :

E-mail address :

Local Address :

Phone No :

Date of starting internship :

Date of completion of internship : ________________

Signature : _________________
 GENERAL GUIDELINES AND INSTRUCTIONS FOR INTERNSHIP

1) The intern must attend the postings regularly and maintain punctuality.

2) On the first day of the posting itself, the intern must obtain the unit’s Heads/Staff i/c signature
at the appropriate places of the log Book.

3) On completion of the postings, the intern must get the Unit Head’s signature on the last day
itself and never postpone it. Subsequently the intern must obtain the Completion Certificate
from the HOD immediately thereafter.

4) On completion of all the postings, the Log Book (complete in all respects) including the
Certificates of Completion (printed in the Log Book itself), duly signed by the respective of
dept, should be submitted to HOD Anesthesiology and final certificate will be issued by the
Medical Superintendent.

5) Internship shall not be started without the logbook.

6) The logbook contains the record of work done by the intern and must be signed by appropriate
authority.

7) The total duration of internship is 6 MONTHS .

8) It is compulsory to maintain daily attendance.

 FOREWORD
Internship is a phase of learning wherein a graduate is expected to apply his knowledge in
practice and acquire medical, behavioral and attitudinal skill under supervision so that he is
able to function independently in practice at the end of internship.

In order to ensure a structured pattern of internship, which can be assessed and

monitored objectively, it was decided by the authorities to maintain logbook for interns.

The purpose of this logbook is to facilitate learning during their posting. It explains the
objectives of the programme, rules and regulation, as well as the expectations from them. This
will also help us in evaluating the programme and deciding whether the internship has
achieved its objectives or not. We hope this logbook will go a long way in achieving the
desired purpose.

Prof & Head Medical Superintendent

Dept of Physiotherapy Medical College & Hospital
 INTERNSHIP: DISCIPLINE RELATED (OPERATION THEATRE)

Internship is a phase wherein a graduate is expected to conduct actual practice of

medical and health care and acquire skills under supervision so that he may become capable
of functioning independently. The aim of this internship is to evaluate the training of Operation
Theatre technician and to ascertain their eligibility During this period of internship, an intern
must be able to: -

1. Assist the surgical team in the following areas: -

(a) Ensuring sterility of equipment & surgical field.

(b) Assisting Anaesthetist in loading & preparation of drugs, stocking of emergency

drugs & equipment, checking of anaesthesia machine & assisting during procedures.

(c) Layout of surgical trolleys & assistance in surgical procedure.

(d) Assistance in ICU and during transport of patients.

(e) Able to resuscitate a patient of cardiac arrest and to be competent as BLS provider.

(f) Able to manage & monitor a patient on blood transfusion & on IV drug infusions.

(g) Assist in receiving & managing patients in emergency Department.

(h) Able to provide basic management in anaphylaxis, head injury, vertebral and

pelvic injuries
Number Section Heading Number of competencies

Section I Cardio-pulmonary

Section II Orthopedics

Section III Neurology&Neurosurgery

Section IV Pediatrics

Section V Rehabilitation

Section VI Evidence based practice

 INTERNSHIP –TIME DISTRIBUTION

Sr No Name of Department Period/Days

(i) Orientation Programme 15 days
(ii) Microbiology and Sterilization aspects 30 days
(iii) For casualty 30 days
(iv) For equipment and maintenance 30 days
(vi) Record Keeping 30 days
(vii) In all OTs 230 days

OT DEPT

Sr No Name of Department Period/Days

(i) Gen Surgery 26
(ii) Orthopedics Surgery 26
(iii) Gynecology & Obstetrics Surgery 26
(iv) Neurosurgery 26
(v) Eye & ENT 26
(vi) Anesthesia 26
(vii) Urology & Endoscopic Surgery 26
(viii) GI Surgery 26
(ix) Vascular surgery 22
Total = 230

Prof & Head

Dept of Anaesthesiology & Critical Care
Narayan Medical College & Hospital

OPERATION THEATRE

(FOR MICROBIOLOGY AND STERILIZATION ASPECTS)

Rotation from ___________________ to ________________

Name of the Unit Head _____________________________________

Attendance report:

No of days attended : ________________________

No of days absent : ________________________

Extension, if any : ________________________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
1. Introduction about all Medical and Surgical aspects in OT
2. Common antiseptics used in OT for Floor disinfection and
carbonization.
3. Preparation of antiseptic solution in common use in
operation theatre, e.g. Endoscopes, tubes, Surgical
instruments
4. Principles of working, Care and maintenance –Steam
Sterilizers (Autoclave) Work - time / temp / pressure
5. SOP of sterilization: Before and after Care of sterile items
(Packing, Sorting and Store /Dispatch)
6. Maintenance of log book each and every sterilization cycle
(Record keeping of load, Bowidick Test, Indicators)
7. sterilization methods in operation theatre, Fumigation
procedure, Fogger methodology – time, record keeping,
8. Collection, transport, labeling, record keeping, informing of
swabs in OT after fumigation.
 9. Sterilization of blunt and sharp instruments, rubber goods
and Electric cautery and suture, ligatures
10. Proper disposal of OT generated Bio Medical waste and
dispose of sharp items (Ampoules, Vial, Needles)
11. Washing, cleaning, testing and repairing of gloves and
preparing them for sterilization and packing.
12. Preparation of dressings, swabs and packing of drums for
sterilization.
13. Brief knowledge about Central sterile supply Dept.
(Autoclave, ETO and Plasma sterilizer)
14. Principles of working, Care and maintenance –ETO and
Plasma Sterilizers, Work - time / temp / pressure
15. sterility test. Collection, site and dispatch of samples for
sterility.

Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer Sign of the Unit head

Sign of the HOD

 OPERATION THEATRE

(FOR CASUALTY)

Rotation from ___________________ to ________________

Name of the Unit Head _____________________________________

Attendance report:

No of days attended : ________________________

No of days absent : ________________________

Extension, if any : ________________________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
1. Familiarization with all the equipments and drug
crash-cart
2. Brief knowledge about the SOP of receiving a
casualty in MI Room
3. Assisted in receiving & managing patients in
emergency situation
4. Maintenance of Emergency Crash cart and to keep a
record
5. Updating the Cardiac Care Ambulance in a routine
order
6. Smooth Availability and care of Oxygen Cylinder in
an emergency situation
7. Data maintenance in MI Room and record keeping
8. Record keeping of all issued medicine and minor
procedures
9. Assisted in Emergency Tracheal intubation
 10. Preparation of trolly for tracheostomy in an
emergency
11. Resuscitated a patient of cardiac arrest and
competent as BLS provider, assisted in Code Blue
alarm
12. Recovery of traumatized patient at an early first aid
method like provision of scoop stretcher, immobilizer
and effective treatments
13. Insertion of IV cannula, Ryles/ NG Tube and foleys
catheter
15. Record keeping of all expendable, Non Exp and
Sophisticated equipments

Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer Sign of the Unit head

Sign of the HOD

 Certificate of Clinical Competence in

Physiotherapy

This is to certify that Mr. / Ms.

_______________________________________

Has successfully completed all required clinical

competencies for completion of Internship rotation at

CLINICAL HEAD MEDICAL

COORDINATOR DEPARTMENT OF PHYSIOTHERAPY SUPERINTENDENT
 RULES

In the hospitals interns are required to be in clinics on time.

Dress code –

- All students and interns must dress in a professional manner.

- The Physiotherapist will be expected at all times to dress to the highest

standards and to present a clean and hygienic appearance.

- No denim is to be worn.

- No visible body piercing to be worn or inappropriate hairstyle

- Hair styles should reflect a professional image. Long hair should be tied back.

- Jewelry that may cause risk to clients shouldn’t be worn.

- Non slip professional footwear must be worn at all times.

Equipment to be carried–

Goniometer, measuring tape, reflex hammer, stethoscope should be carried by students and interns
during posting

Safety equipment–

Every student and intern should have a transfer belt with him or her. It is necessary for

patient safety.

OPERATION THEATRE

(RECORD KEEPING)

Posting from ___________________ to ________________

Name of the Unit Head _____________________________________

Attendance report:

No of days attended : ________________________

No of days absent : ________________________

Extension, if any : ________________________ No of days

 S No Activities Performed by the Intern to be Signature of
recorded below Staff with Date
1. Maintenance of various OT Register (Major and Minor
surgery)
2. Specimen collection, dispatch and record keeping of
specimen
3. Maintenance of Anesthesia register
4. Maintenance of various register in Pre and Post
Operative and data keeping of duration of Post
anesthesia recovery
5. Log book maintenance of all sophisticated equipments
6. Preparation and calculation of daily used drugs
7. OT maintenance register (Time, place and specimen
collection method and report)
8. Record keeping of Expandable items
9. Preparation of sophisticated items as per requirement
10. Documentation for Procure reequipments and to carry
a technical inspection
11. Preparation of Complied OT list and safe record
keeping
12. Monthly data collection from various specialization and
dispatch
13. Maintenance of OT Register like Infection control,
Adverse event, routine care of Instruments etc.
14. Brief knowledge about all the OT related documents
15. Record keeping, safe custody and abuse of
anesthesia drugs

Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.
Any other remarks

Sign of the OT In-Charge officer Sign of the Unit head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

S No Activities Performed by the Intern to be Signature of
recorded below Staff with Date
1. Familiarisation with all OT Instruments and
Equipments
2. Trolly Layout of General Instrument
3. Maintenance of Instruments and Equipment after each
and every surgery procedure
4. Indenting procedure and calculation of MMF
5. Patients surgical site preparation before ACL tear
knee Arthroscopy and proceed, Endoscopic
instrument layout and maintenance of Arthroscopy
equipment
6. Assisted in Screw and plate removal
7. Operating procedure, Preventive majors and
maintenance of C- Arm in Orthopedics OT
8. Store keeping and layout of Ortho Implants
9. Sterility confirmation of instrument and all equipments
working condition one day prior to surgery
10. Indent –Collection, Receiving and Record Keeping
11. Use of Tourniquet, sites of tourniquet placement and
pressure required for lower and upper limb
12. Knee Arthroscopy, Specimen collection for biopsy,
labelling
13. Use and names of Arthroscopic instrument
14. Patient positioning – Shoulder Arthroscopy and
proceed surgery
15. Assisted in Proximal Femoral Nailing Anti-rotation
surgery
16. Various parts of Arthroscopy Equipment and their
maintenance
17. Hip Replacement Arthroplasty and proceed
18. Use, care and maintenance of Manman instrument.
Use of saw in Hemi Arthroplasty
19. Assisted in Wound Debridement and Implant removal.
20. Types of POP. Application of Cast, Slab.
21. Surgical site dressing, stapler removal and suture
removal.
22. Assisted in Surgical synovial Biopsy
23. fracture and surgery procedure
24. Inventory Management, Storage of Implants and all
other sophisticated, Non Electromedical equipments.
25. Familiarization with all types Implants like Plates,
Screws
26. Layout of Trolly for Knee Arthroscopy
27. Brief knowledge about special surgical instrument and
their uses during surgical procedure
28. Layout of Trolly for Total Knee Replacement and
implants
29. Maintenance of ledger after every surgical procedure
30. Preparation of OT List and all required surgical
instrument, Implants
Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge Sign of the Unit head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

SNo Activities performed by the intern to be Signature of Staff with date

recorded below
1) Familiarisation with all OT Instruments and
Equipments
 2) Brief knowledge about General Anaesthesia and
emergency drugs used in OT
3) Preparation of Spinal Trolley for spinal
anaesthesia
4) OT preparation for Laparotomy under GA and
TAP block
5) Checking and function of Anaesthesia machine
each-day prior to OT start up
6) Preparation of anaesthesia drugs under guidelines
of Faculty
7) Trolley for Central Line insertion and knowledge
about site of insertion
8) Maintenance of OT and all surgical equipment
9) Assisted in CSEA (Combined Spinal Epidural
Anaesthesia)
10) Investigations required in Pre-Anaesthesia Check
up
11) Importance of Consent and types
12) Insertion of IV cannula, patient positioning and
Post recovery position
13) Care and Maintenance of USG machine after
every Invasive procedure
14) Types of Gas Cylinder and differentiate with color
coding
15) A Brief knowledge about MGPS (Medical Gas
Plant System) and color coding of pipelines
16) Use, Care and maintenance of HFNC (High Flow
Nasal Cannula)
17) Assisted in CVP and Arterial line insertion
18) Preparation of OT for difficult intubation of patient
with the help of Bronchoscope
19) Documentation and chart fill-up and calculation of
fluid during surgery
20) Assisted in DLT (Double Lumen Tube) insertion
21) Safety features of Anaesthesia machine
22) Active presence and monitoring of CVP and ICP
during Neurosurgery
23) Fluid resuscitation and use of fluids
24) Daily drug maintenance and collection and safe
disposal of used drugs
25) Bio medical Waste Management
26) Use of Video Laryngoscope, assisted in difficult
airway intubation
27) Patient resuscitation during emergency situation
28) Brief knowledge of types and modes of Ventilator
29) Patient position during Spinal Anaesthesia and
drawbacks
30) Knowledge about Surgical Safety Checklist

Assessment Scale:
 S No Indicator for assessment 0 to 5
1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer Sign of the Unit head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
1. Familiarisation with all OT General gynae Instruments
and Equipments
2. Trolly Layout of General Instrument
3. Maintenance of Instruments and Equipment after each
and every surgery procedure
4. Indenting procedure and calculation of MMF
5. Patients surgical site preparation before TAH and
instrument layout and maintenance of Instrument’s
6. Trolley preparation and Assisted in C-Section
7. Operating procedure, Preventive majors and
maintenance of laparoscopic instruments and
equipments in OT
8. Store keeping and indenting of expendable items
9. Sterility confirmation of instrument and all equipments
working condition one day prior to surgery
10. Indent – Collection, Receiving and Record Keeping
11. Use of Harmonic, Ligature, diathermy, sites of
placement patient plate and their maintenance
12. D&C, D&E and S&E trolley layout and Specimen
collection, labelling and dispatch for HPE
13. Use and names of Laparoscopic instrument
14. Trolley layout and Patient positioning – VHR surgery
15. Assisted in Open Myomectomy surgery and use of
special instruments
16. Various parts of laparoscopic Equipment and their
maintenance
17. Stagging laparotomy and proceed

18. Use, care and maintenance of Surgical instrument.

19. Assisted in Laparoscopic Surgery
20. Record keeping of ANC Profile and management of
patient in Gyn OPD
21. Surgical site dressing, stapler removal and suture
removal.
22. Assisted in Diagnostic Hystoscopy .
23. DHL trolley layout and and surgery procedure
including laparoscopic equipments
24. Inventory Management, Storage of Expendable items
and all other sophisticated, Non Electromedical
equipments.
25. Familiarization with all procedure and requires
diagnostic procedure
26. Layout of Trolly for Tubal recanalisation
27. Brief knowledge about special surgical instrument and
their uses during surgical procedure
28. Layout of Trolly for Laparotomy and proceed
29. Maintenance of OT register after every surgical
procedure and summary of OT (Major and Minor
procedure)
30. Preparation of OT List and all required surgical
instrument, expendable items
Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer Sign of the Unit head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with
Date
1. Familiarisation with all Neuro surgical Instruments and
Equipments used in Neuro OT
 2. Trolly Layout of Neuro General Instrument
3. Maintenance of Sophisticated Instruments and Equipment after
each and every surgical procedure
4. Regular, Emergency Indenting procedure and calculation of MMF
5. Patients surgical site preparation before surgery (Primary) and
positioning, use of Sugita, Horse shoe in Craniotomy
6. Trolley prepared and Assisted in Craniotomy
7. Operating procedure, Preventive majors and maintenance of
Neurosurgical Microscope, C-Arm and equipments used in OT
8. Store keeping and indenting of expendable items
9. Sterility confirmation of Neuro instrument and all equipments
working condition one day prior to surgery
10. Indent – Collection, Receiving and Record Keeping
11. Use of Surgical diathermy, sites of placement patient plate and
their maintenance
12. Left Frontal AVM (Arteriovenous Malformation) trolley layout and
Specimen collection, labelling and dispatch for HPE
13. Patients surgical site preparation before surgery (Primary) and
positioning, use of Wilson Frame, Longitudinal Bolster in
Laminectomy
14. Trolley layout and Patient positioning – Right Frontal High-Grade
Glioma – Craniotomy surgery
15. Assisted in Laminectomy with posterior Pedicle Screw fixation
surgery and use of special instruments
16. Operation of C-Arm, Care and maintenance of C –Arm
17. Excision of Tumor using Neurosurgical microscope
18. Use, Care, installation and maintenance of STB (Stereotactic
Brain Biopsy) Frame and updation of software.

19. Assisted in VP shunt (High, Low and Medium) insertion

20. Record keeping of surgical expandable (Tissel, Floseal)
21. Surgical site dressing, stapler removal and suture removal.
22. Assisted in EVD (External Ventricular Drainage) in Emergency
ICU setup.
23. Craniotomy trolley layout and and surgery procedure including
Dural set
24. Inventory Management, Storage of Expendable items and all
other sophisticated, Non Electromedical equipments.
25. Familiarization with all procedure and requires diagnostic
procedure
26. Layout of Trolly for Laminectomy L5-S1.
27. Brief knowledge about special surgical instrument and their uses
during surgical procedure
28. Use, care and maintenance of CUSA For malignant tissue
(Cavitronic Ultrasonic surgical Aspiration)
29. Maintenance of OT register after every surgical procedure and
summary of OT (Major and Minor procedures)
30. Preparation of OT List and all required surgical instrument,
expendable items one day prior to OT Day

Assessment Scale:
 S No Indicator for assessment 0 to 5
1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer. Sign of the Unit Head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
1. Familiarisation with all ENT surgical Instruments and
Equipments used in ENT OT
2. Trolly Layout of General Instrument for FESS
3. Maintenance of Sophisticated Instruments and
 Equipment after each and every surgical procedure
4. Regular, Emergency Indenting procedure and
calculation of MMF
5. Patients surgical site preparation before surgery and
positioning
6. Trolley prepared and Assisted in DNE Procedure
7. Operating procedure, Preventive majors and
maintenance of Microscope and equipments used in
OT
8. Store keeping and indenting of expendable items
9. Sterility confirmation of ENT instrument and all
equipments working condition one day prior to surgery
10. Indent – Collection, Receiving and Record Keeping
11. Trolley prepared and Assisted in Tympanoplasty
Procedure
12. Assisted in Surgical dressing and suture removal in
Minor OT
13. Familiarization with all endoscopic procedure in OPD
procedure
14. Trolley layout and Patient positioning –DL Scopy and
Biopsy
15. Maintenance of OT register, Preparation of OT List
and Storage of all Expendable items.

Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behavior with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer. Sign of the Unit Head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
1. Familiarisation with all Eye surgical Instruments and
 Equipments used in EYE OT
2. Trolly Layout of General Instrument for Eye surgery
3. Maintenance of Sophisticated Instruments and
Equipment after each and every surgical procedure
4. Regular, Emergency Indenting procedure and
calculation of MMF
5. Pre operative drugs and Patients surgical site
preparation before surgery
6. Trolley prepared and Assisted in PHACO Procedure
7. Operating procedure, Preventive majors and
maintenance of Keratometer (IOP AND AR)
8. Store keeping and indenting of expendable items
9. Using Flash sterilization for EYE instrument in
continuous surgery
10. Indent – Collection, Receiving and Record Keeping
11. Trolley prepared and Assisted in Cornea transplant
Procedure
12. Assisted in Surgical dressing and post operative care
preventive majors
13. Familiarization with all equipments in OPD and minor
OT procedure
14. Trolley layout and Patient positioning –PCIOL
15. Maintenance of OT register, Preparation of OT List
and Storage of all Expendable items.

Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behavior with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer. Sign of the Unit Head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
1. Familiarisation with all OT Urological Instruments and Equipments
2. Trolley Layout of General Instrument
3. Maintenance of Instruments and Equipment after each and every OT
4. Indenting procedure and calculation of MMF
 5. Patients surgical site preparation before TURP
6. Assisted in CPE
7. Operating procedure, Preventive majors and maintenance of C- Arm
8. Store keeping and layout of Uro Expandable items
9. Sterility confirmation of instrument and all equipments working condition
one day prior to surgery
10. Indent –Collection, Receiving and Record Keeping
11. Use of Tourniquet, sites of tourniquet placement and pressure required
for lower and upper limb
12. Laparoscopy, Specimen collection for biopsy, labelling
13. Use and names of Laparoscopic instrument
14. Patient positioning – Kidney transplant and surgery procedure
15. Assisted in Prostate Surgery
16. Various parts of Laparoscopic Equipment and their maintenance
17. Trolley layout for Cystoscopy and proceed
18. Use, care and maintenance of Urethroscopy
19. Assisted in Surgical dressing in post operative care patients
20. Trolley layout for Male circumcision and assisted in surgical procedure
21. Surgical site dressing, stapler removal and suture removal
22. Assisted in Prostate biopsy
23. Aspiration (MESA) procedure
24. Inventory Management, sophisticated & Non Electromedical
equipments.
25. Familiarization with all types Surgical expendable items
26. Layout of Trolley for Transurethral Resection Prostate (TURP)
27. Brief knowledge about special surgical instrument and their uses
28. Layout of Trolley for Phimosis and assisted in procedure
29. Maintenance of ledger after every surgical procedure
30. Preparation of OT List and all required surgical instrument

Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer Sign of the Unit head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
1. Familiarisation with all GI Instruments and Equipments
2. Trolley Layout of General Instrument
3. Maintenance of Instruments and Equipment after each and every OT
4. Indenting procedure and calculation of MMF
5. Patients surgical site preparation before Laparoscopic Surgery
 6. Assisted in Lap Appendectomy
7. Operating procedure, Preventive majors and maintenance of
Laparoscopic Machine
8. Store keeping and layout of GI Expandable items
9. Sterility confirmation of instrument and all equipments working condition
one day prior to surgery
10. Indent –Collection, Receiving and Record Keeping
11. Use of CUSA in Malignant GI Surgery
12. Laparoscopy, Specimen collection for biopsy, labelling
13. Use and names of Laparoscopic instrument
14. Patient positioning – in various Surgery procedures
15. Assisted in Surgical Staplers in GI Surgery
16. Various parts of Laparoscopic Equipment and their maintenance
17. Trolley layout for Laparotomy and proceed
18. Use, care and maintenance of Electrosurgical Equipments
19. Assisted in Surgical dressing in post operative care patients.
20. Trolley layout for Lap Cholelithiasis and assisted in surgical procedure
21. Surgical site dressing, stapler removal and suture removal.
22. Assisted in Surgical site preparation
23. Use, Care and maintenance of Surgical Harmonic
24. Inventory Management, sophisticated & Non Electromedical
equipments.
25. Familiarization with all types Surgical expendable items
26. Layout of Trolley for Lap Splenectomy
27. Brief knowledge about special surgical instrument and their uses
28. Layout of Trolley for Lap Hernioplasty and implants
29. Maintenance of ledger after every surgical procedure
30. Preparation of OT List and all required surgical instrument

Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer Sign of the Unit head

Sign of the HOD

OPERATION THEATRE

(____________________________________________)

Rotation From ___________________ to ___________________

Name of the unit Head ____________________________________

Attendance report:

No of days attended : ___________

No of days absent : ____________

Extension if any : ______________ No of days

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
1. Familiarisation with all surgical Instruments and
Equipments used in vascular surgery.
2. Trolley Layout of General Instrument for Flip flap
surgery
3. Maintenance of Sophisticated Instruments and
Equipment after each and every surgical procedure
4. Regular, Emergency Indenting procedure and
calculation of MMF
5. Patients surgical site preparation before surgery
and positioning
6. Trolley prepared and Assisted in SSG (Surgical
Skin Graft) Procedure
7. Operating procedure, Preventive majors and
maintenance of equipments used in OT
8. Store keeping and indenting of expendable items
9. Sterility confirmation of surgical instruments and all
equipments working condition one day prior to
surgery
10. Indent – Collection, Receiving and Record Keeping
11. Trolley prepared and Assisted in Nail removal
(IGTN) Procedure
12. Assisted in Burn dressing and suture removal in
Minor OT
13. Trolley prepared and Assisted in Free flap, grafting
Procedure
14. Trolley layout for B/L syndactyly

S No Activities Performed by the Intern to be Signature of

recorded below Staff with Date
15. Familiarisation with all Vascular surgery OT Instruments
and Equipments
16. Trolley Layout of General Instrument
17. Suture and stapler removal in Minor OT Procedure

18. OT preparation for AV Fistula and operating procedure

19. Maintenance of Instruments and Equipment after each and

every surgery procedure
20. Assisted in Skin Grafting Surgery
21. Trolley preparation for Varicose Vein and assisted

22. Assisted in Vacuum Dressing and suturing

23. Trolley layout for Thrombectomy and surgical site
preparation
 24. Maintenance and sterility of dressing material in Minor OT

25. Care and handling of Micro Vascular Surgical Instrument

26. Surgical sutures used Vascular Surgery i.e. CV Suture

27. Assisted in suturing and dressing, Grafting

28. Trolley Layout of AV Fistula
29. Trolley preparation and assisted in wound debridement
and Skin Grafting
30. Maintenance of Instruments and Equipment used in
Vascular OT
31. Indenting and indent collection from Medical Store

32. Preparation of OT list and dispatch

33. Collection of surgical sample and proper dispatch, report
collection
34. Sterility confirmation of RSC surgical instruments and all
equipments working condition one day prior to surgery

Assessment Scale:

S No Indicator for assessment 0 to 5

1. Knowledge
2. Skill
3. Responsibility, work-up of cases and punctuality
4. Behaviour with colleagues, nursing staff and others
5. Initiative, participation in discussion and research
aptitude

Key: 0-Poor; 1-Fair; 2-Below average; 3-Average; 4-Above average; 5-Excellent

A score of less than 3 in any of the above items indicates unsatisfactory internship.

Any other remarks

Sign of the OT In-Charge officer Sign of the Unit head

Sign of the HOD

Annexure:I

FORMAT OF POSTINGS

Name of the College: Narayan Medical College & Hospital

Ref. No ……………………… Date …………………….

CERTIFICATE

This is to certify that Mr ………………………………………………………………………

Has undergone One-year unpaid Compulsory Rotatory Internship from …………………… to

……………………….. details of the posting in various departments are as follows:

Sr No Name of Department Period
(i) Orientation Programme To
(ii) Microbiology and Sterilization aspects To
(iii) For casualty To
(iv) For equipment and maintenance To
(vi) Record Keeping To
(vii) In All OTs To

Prof & Head Medical Superintendent

Dept of Anaesthesiology & Critical Care Narayan Medical College & Hospital
Narayan Medical College & Hospital
INTERNSHIP PERFORMANCE DATA BOOK

Batch : _________________________

Academic Course and Year : _________________________

Name of Intern : _________________________

Year of admission : _________________________

Year of Passing : _________________________

Date of Starting Internship : _________________________

Date of completion : _________________________

 CERTIFICATE

Name of the intern : __________________________________________________________

Internship posting started on : _____________________ Completed on ______________

No of days repeated due to absentee: ____________________________________________

Reason for repetition : ____________________________________________________

Remarks
Ser Period of posting Attend Sign
Name of Department of HOD
No ance
From To
1. Orientation /15
Programme
2. Microbiology and /30
Sterilization aspects
3. For casualty /30

4. For equipment and /30

maintenance
5. Record Keeping /30

6. In All OTs /230

(i)
7. Repetition, if any (ii)
(iii)
(iv)

Recommended/Not recommended to issue internship completion certificate

Prof & Head Medical Superintendent

Dept of Anaes & Critical Care Narayan Medical College & Hospital
Narayan Medical College & Hospital
LEAVE DETAILS

Ser Leave Signature of OT In-Charge

No From To

Prof & Head

Dept of Anaesthesiology & Critical Care
Narayan Medical College & Hospital