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Clerking A Patient Dr. Ragaul Rajagopal (FY2 LAS – EDGH) What Is Clerking? • Clerking a patient is the process of gathering information about a patient's condition, performing a physical exam, and documenting the findings in the patient's medical records. • It's usually done by doctors in training before a senior doctor reviews the patient.Current Clerking Booklet Elements • Delirium assessment – 4AT test • Patient details • Dementia screening tool – for all emergency admissions • Admission details aged 75 or over • Investigations • Presenting complaint and history • Diagnosis • Past medical history • Co-morbidities • Family history • Management Plan • Co-morbidities to consider • Social history • Risk assessment for Venous Thromboembolism (VTE) • Frailty assessment • Risk assessment – Upper GI bleeding • Systems review • Diabetes assessment • Blood test results • Current medication • Known allergies • Blood gas results • Examination of patient • Drug level results • Post-admission consultant ward round assessment • Nervous system • Post-admission consultant ward round – diagnosis and management plan Documentation Basics • What should I use to write with? • Black Ink • Patient Details • 3 Key Identifiers • Full name • Date of birth • Unique patient identifier • Home address • Location Details • Hospital • WardBeginning Your Entry In The Notes • The next documentation steps include: 1. Adding the date and time (in 24-hour format) of your entry. 2. Writing your name and role as an underlined heading. 3. Adding your entry in the notes below this heading. Documenting The History • When documenting a history, it’s important to apply a structured approach. • Presenting Complaint • has presented with (e.g. “chest pain”).w words describing the specific issue the patient • Make this short and to the point, there is space in the next section to expand further. Documenting The History • History of Presenting Complaint (HPC) • This section allows you to expand on the presenting complaint. • If the symptom is some kind of pain you might use the SOCRATES structure to gather more details about it: • Site: clarify the location of the pain (e.g. central chest). • Onset: determine if the pain has come on suddenly or gradually. • Character: assess the type of pain (e.g. burning, sharp or aching in nature). • myocardial infarction).ain moves anywhere else (e.g. radiation to the arm from the chest in • fever, shortness of breath)out other symptoms which are associated with the pain (e.g. • Time course: clarify the duration of the pain (e.g. hours, days, weeks or months). • Exacerbating/relieving factors: ask if anything makes the pain better or worse. • Severity: assess the patient’s subjective experience of the pain’s severity on a scale of 0-10. Documenting The History • Past Medical And Surgical History (PMH) • The past medical and surgical history section is where you document any medical conditions the patient is known to have, any significant hospital admissions and any surgical history (e.g. operations/procedures). • Drug History (DHx) • Medications the patient is currently prescribed • Medications the patient is buying over the counter (often referred to as ‘OTC’) • Drug allergies • Any compliance issues (e.g. if the patient is prescribed something but actually has chosen not to take it) Documenting The History • Family History (FHx) • The family history section is where you document any diseases that run in a patient’s family (generally the focus should be on first-degree relatives). • Drawing out a family tree can be useful to identify patterns of inheritance if the disease is genetic. • Social History (SHx) • The social history section is where you document the various social aspects of the patient’s life that may be relevant to their condition (e.g. health risk factors) and their safety at home. • Topics can include: • Who the patient lives with • Details of the patients home (e.g. whether they have stairs) • Smoking history • Alcohol history • Recreational drug use • Occupation Documenting The History • Systems Review (SR) • relate to their presenting complaint. It may be useful to start at the top of the body and move down, or you may have your own structure, do whatever works best for you. Documenting The History • History Abbreviations • History sections • PC = Presenting complaint • HPC = History of presenting complaint • PMHx = Past medical history • SR = Systems review • DHx = Drug history • FHx = Family history • SHx = Social history • Time abbreviations • Number of days = number of days/7 – (e.g. 3/7 = 3 days) • Number of weeks = number of weeks/52 – (e.g. 4/52 = 4 weeks) • Number of hours = Xº – (e.g. 8º = 8 hours) Documenting The History • Common abbreviations used for medications • OD = Once daily • BD = Twice daily • TDS = Three times daily • QDS = Four times daily • PRN = As required • SC = Subcutaneous • IM = Intramuscular • IV = Intravenous • Remember not to abbreviate on patient prescriptions (FP10) or patient discharge letters.Documenting The Clinical Examination • On Examination (O/E) • Start by documenting your general inspection (e.g. “The patient was laid on the bed and appeared to be in significant pain”). • Observations (Obs/Vitals) • This is where you document the patient’s current observations/vital signs (e.g. BP/Pulse/Respiratory rate/Oxygen saturation/Temperature). • Fluid Balance • If the patient’s fluid balance is being monitored write down the input (drinking/IV/NG) and output (urine/stools/drains) that has been measured.Documenting The Clinical Examination • Focused Clinical Examination Findings • Here you can document the focused system examinations you have performed, with the associated findings. • Examples of focused system examinations include: • Cardiovascular examination (CVS) • Respiratory examination (Resp) • Gastrointestinal examination (G.I.) • Neurological examination (Neuro)Documenting The Clinical Examination • Examination abbreviations • Some common abbreviations used when documenting clinical examination include: • O/E = On examination • BP = Blood pressure • RR = Respiratory rate • Sats = Oxygen saturation • RA = Room air (when placed next to oxygen saturation) • I + II + 0 = Heart sounds 1 and 2 heard, with no added sounds • II + II + I = Heart sounds 1 and 2 heard, with an additional sound (e.g. murmur) • BS = Bowel sounds • RUL/LUL = Right upper limb/Left upper limb • RLL/LLL = Right lower limb/Left lower limb • CN = Cranial nerve (usually followed by a number e.g. CN 1)Documenting The Clinical Examination • Examination DiagramsDocumenting The Clinical Examination • Examination DiagramsDocumenting The Diagnosis/Differential Diagnosis • In this section of the clerking, you need to document a diagnosis or suggest a differential diagnosis. • Most of the time when you clerk a patient you won’t have a confirmed diagnosis and therefore you’ll need to document some possible differential diagnoses. • The symbol for a diagnosis is a singular triangle. • The symbol for differential diagnosis is two triangles next to each other.Documenting The Management Plan • In this section, you need to document your plan in the form of a list. • This makes it clear to others reading the notes which investigations are underway and what interventions are planned.Completing The Entry In The Notes • At the end of your entry to need to include the following: • Your full name • Your grade/role (e.g. Medical student/F2/Respiratory Registrar) • Your signature • Your professional registration number (e.g. GMC number) • Your contact number (e.g. phone/bleep) References • Royal College of Physicians. General medical record-keeping standards. • General Medical Council (2023) Good Medical Practice 2024. United Kingdom: General Medical Council. Any Questions? Thank you! Please could everyone complete a short feedback form!