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

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