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Admission clerking

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


  • 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


  • 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 


  • 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

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