Admission clerking

Clerking and reviewing patients > Clerking patients

Take history and examine patient

Take a full history (see section on histories )
Examine patient (see section on examinations)
- Look at the observations chart
- You should do a basic multi-system exam for all new admissions
  - Respiratory: cyanosis, percussion note, lung sounds, calf swelling/tenderness
  - Cardiovascular: capillary refill, pulse (rate/rhythm), JVP, heart sounds, peripheral oedema
  - Abdominal: tenderness, masses/organomegaly, bowel sounds
  - Nervous system: GCS, limb movements, abbreviated mental test score if elderly/confused
- Examine the relevant system in more detail and specifically document the presence/absence of signs of differential diagnoses
Review any investigations that have already been performed (e.g. bloods, X-rays etc.)
Formulate a differential diagnosis/impression/problem list and plan investigations/management based on the above

Document

Date and time
Patient age and sex
History
- Presenting complaint
- History of presenting complaint (e.g. main symptoms as separate major bullet points, with sub-bullet points exploring each symptom, and then relevant system reviews as further major bullet points – include relevant positives and negatives)
  - Symptom A
    - Explore
    - Explore
  - Symptom B
    - Explore
    - Explore
  - Relevant system review A
  - Relevant system review B
- PMHx (supplement with information from computerised records)
- DHx (including allergies)
- FHx (relevant conditions)
- SHx (must be very thorough in elderly patients – get collateral)
Examination
Investigation results so far
Differential diagnosis/impression/problem list
Plan
- Investigations
- Management
- Other considerations
Sign with name, role, bleep

Arrange investigations

Perform
- Site cannula and take bloods from cannula (consider doing this before taking a history so results are back quicker)
- Undertake other relevant investigations, e.g. ABG, lumbar puncture, blood cultures
Ask nursing staff
- Bedside tests, e.g. ECG, urine dip (± MC&S), swabs
Order
- Relevant imaging
- Any other tests required

Implement management

Implement ABCDE management as necessary, e.g. oxygen, fluids
Fill in drug chart
- Disease-specific treatments
- PRN analgesia ± antiemetics ± antipyretic if required
- Regular medications
- DVT prophylaxis (e.g. LMWH/fondaparinux ± anti-embolism stockings)
Order/perform any other disease-specific interventions
Fill in a VTE assessment
Keep patient NBM if surgery may be required

Review

Note down the patient’s details and which investigations need to be chased (use fill-in boxes – half fill when taken/requested, fully fill when result back and checked)
Follow-up the results and document them in the notes
Change/initiate treatments if needed
Present to seniors (when initial investigation results are back) and implement any additional management plans required

Tips!

You will need to write quickly during the consultation but try to ensure the patient is still the main focus
Look through all the computerised records (e.g. GP record, discharges, letters, investigation results) for the patient to supplement the past medical/drug history
In some elderly patients, you may need to call the next of kin or nursing/residential home for collateral history (find out what happened and get more information about past/drug/social history and their baseline)
Ensure you are leading the consultation – learn how to interrupt patients politely. If the patient is very talkative, use closed, focussed questions.
Never forget your communication skills – introduce yourself properly, use the patient’s name, shake their hand, build rapport, start with open questions and find out their ideas, concerns and expectations

Learn more…

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