How to clerk medial patients safely and efficiently

This blog post is for medical doctors and other allied health professionals who clerk patients. I am going to go through some basics first.

What is clerking?
This is a process whereby patients admitted under the medical specialty are seen by a junior member of the team and then the patient is seen by a consultant ( known as post take). There is a special clerking proforma which has the following sections:
1. Clerking doctors details: Name, role, GMC number, signature, Time and date
2. Presenting complaint and history of presenting complaint.
3. Past medical history
4. Social history
*SMOKING
- Smoker/ex smoker/non smoker
-How much does/did (s)he smoke a day
- If nicotine replacement therapy has been advised - if the patient has accepted/declined it
*ALCOHOL
-How many units a week
- High/low risk?
*Social circumstances
- Whether (s)he lives alone
- Any carers - if yes, how many times a day
- Dependence level with activities of daily living ( whether needs assistance with washing, dressing, cooking, shopping)
- Baseline exercise tolerance
5. Family history
6. Allergies
7. Current medication
8. Examination
9. ECG findings
10. CXR/ AXR
11. Any other imaging
12. Differentials/diagnosis
13. Plan
14. Clerking doctors details: Name, role, GMC number, signature, Time and date
How are patients admitted?
Via:
1. Emergency department - these can be via ambulance, walk ins, family/police may have brought them in.
2. Out patient clinics- These patients already have a plan from the clinic on what to do when they are admitted.
3. Through ambulatory care - Ambulatory care unit is a walk in unit attached to AMU/ED where patients are referred by GPs who need to be seen by the medical team the same and are well enough to walk. Sometimes, these patients need to be admitted.
4. GP referrals for direct admission.

Each trust has its own protocols of admitting patients.

Who fills out the medical clerking proforma?
In my trust, which is a small DGH, all patients come through the ED and they are clerked my the ED team on the medical clerking proforma. As clerking doctors, we just add whatever is missing and take a history and examine them again to ensure nothing has been missed.
In other trusts, the ED team fills out an ED clerking proforma and you have to fill out a medical clerking proforma. 

Does this not waste time - ie the ED team clerking patients and then the medical team doing the same?
This is called safety netting. As you can imagine, the ED team is extremely busy and although they do an amazing job stabilizing unwell patients and doing the initial treatment, they may not have time to go through more details.

How do you clerk patients?
FOR STABLE PATIENTS 

1. I get a clerking proforma, fill my details: Name, role, GMC number, signature, Time and date
2. I always start with going through the ambulance sheet record and ALWAYS document the OBS when the ambulance service arrived : BP, temp, RR, SO2, HR, Blood sugar levels, GCS. I document these in the history of presenting complaint
3. I then go through the past admissions and document what happened during the patients previous admission - this is a quick 4 line summary by going through the patients previous discharge summary. I also check any recent out patient clinic appointments and document anything significant.  
4. I then fill out the past medical history based on the patients electronic record 
5. I then go through the summary care record of the patient ( in my trust, the ED ward clerk uploads this on to our electronic system- This contains the allergy status, medications list and sometimes, co-morbidities) and document the medications. I DO NOT prescribe anything ( as this may be an old record or some of these medications may be contraindicated in an acutely unwell patient) 
6. Then I document the patients current OBS (also uploaded onto the electronic system)
7. I then document the investigations: CXR, any other images and bloods. I ALWAYS circle any abnormal results. 
8. NOW, I can go to the see patient - I take a full history ( I already have a general idea based on the ambulance sheet, ED clerking), take a detailed social history ( remember to fill the social history section, this is VERY important). 
9. I examine the patient -
   Make it a habit of doing a systematic examination. Start with looking at the finger nails, check for tremor/flap, hands, check the pulse, eyes, tongue, lymph nodes, JVP.
   CVS: Make it a habit of listening to murmurs. Take time - You will learn how to pick subtle murmurs ( like the ejection systolic murmur of mild aortic stenosis).
   Abdomen: ALWAYS palpate the abdomen. EVEN if the patient says that (s)he does not have pain/is opening bowels regularly.
   Document any pedal oedema, check for clinical signs of DVT ( ie limb swelling)
   CNS: Always do a thorough neurology examination if there is any weakness, the patient had a fall and ALWAYS document it properly Ie cranial nerve examination ( any change in sensation of smell, pupils size, accommodation, reaction to light, nystagmus, diplopia, ask them to smile, clench their teeth, close their eyes shut, check sensation of face, hearing, move tongue from side to side, turn neck against resistance, shrug shoulders against resistance)  power 5/5 bilaterally upper and lower limbs, normal speech, normal reflexes, plantars down going bilaterally 
10. Then I make a list of differentials and inform the patient about my plan. 
11. If the patient is elderly, has poor baseline functional status, I try to discuss DNAR with the patient or relatives if the patient is too unwell. Everyone should fist observe someone do this, then do it under supervision and then do it independently. Of course, if you are unsure then it is best to escalate to a senior colleague. The ability to discuss resus is an art which comes with time and practice. You need to use certain words, have a certain tone and facial expressions when discussing this. A lot of reassurance is needed and hence, please ensure you are confident in doing this. Otherwise, seek help.
12. Request any outstanding investigations. 
13. fill my details again in the end: Name, role, GMC number, signature, Time and date
14. Get a sticker with the patients details and put it on my handover sheet and mention: diagnosis and outstanding investigations - so that I can chase them and document them once these are performed. 

FOR UNSTABLE PATIENTS
I would have already got a SBAR from the ED team. I go through the past medical history on the computer, investigations and OBS.
If the patient is very unstable, then I do not have time to do a full clerking initially like I would for a stable patient so I do an A to E assessment, do a SBAR again and document both.
Once I have done everything, I clerk the patient in detail and add in the extra information which I could not have documented/ asked about when the patient was critical. 

I also re-review the patient later to ensure (s)he has stabilized. 

How long does it take to clerk a patient?

My first clerking ever in the NHS took me 2 hours. But I was very thorough. And the take consultant said that I should continue doing this. This encouraged me a lot. 

Then I started getting the hang of it and learnt some tips ( ie prepare the clerking booklet before seeing the patient ) and it now takes any time from 30 to 45 minutes to clerk a patient. 

However some still take about an hour - especially when they are unwell or when I have to discuss DNARs with the family. 

What are your tips?

1. Be thorough. Please do not try to clear the clerking board instead manage patients properly. Take your time. This is not a rat race. You have an unwell patient in your hands and you are his sole doctor at that point. Your documentation and plan will be very important hence clerk a patient like you would like a doctor to see you. 
2. Do not get overwhelmed. No one should tell you that you are too slow. Tell anyone who says this to you that you are new to this and you want to do it properly. 
3. Always document everything - any investigations, discussions with family members, other specialties etc. Please DO NOT write normal when it comes to documenting blood results.
4. ALWAYS examine the patient properly - you can easily miss cauda equina, strokes, infective endocarditis by doing a 10 second examination on a "poor mobility, back ground of dementia, poor historian" 
5. Keep a log of patients you have clerked.
   - Put a sticker on a piece of paper and mention the outstanding investigations. Sometimes,a small list of relevant co-morbidities can help too ( in case you have to handover this to the other team - ie, a 80 year old smoker, previous stents to LAD 2 years ago, admitted with chest pain, first trop negative, second one awaited)
6. Also, keep an electronic log of your patients in your work folder. DO NOT MAKE A LIST ON YOUR HOME COMPUTER! Some posts like IMT, ST3 now have a mandatory requirement to keep a log - not so detailed but you may need to show your supervisor.
   Plus, you can also see what happened to the patients you clerked later on when you cannot find them on the ward. It is a good learning experience.
7. Treat each patient as your family member - show empathy, go out of your way to help them. They are in pain and you are their "healer". 
8. UPDATE the ceiling of care if you have that option on the electronic system. If they have a DNAR and there is a clear plan for ward based then select that option. If they have DNAR but you are not sure about escalation ( ie whether they are for NIV, inotropes) then select DNAR but refer to outreach/ITU if deteriorates.
9. Please do VTE where appropriate:
   http://omarsguidelines.blogspot.com/2018/02/teaching-session-vte.html 
10. Do not do a half hearted attempt - if you are tired then take a break. Please do not risk managing a patient when you are not in the right mindset. And PLEASE DO NOT clerk a patient when you have 30 minutes to handover. 
11. You should stop clerking 30 to 45 minutes before handover and chase jobs , see any sick ones on AMU and if they have been sorted so that the next team does not have any problems. 
12. Learn to handover outstanding investigations- ALWAYS leave on time. 
13.  See sick patients! You will be scared initially. The registrar will see them anyway but volunteer. I have started as a registrar and I am confident in managing unwell patients because I always volunteered to see the sick ones in my core medical training and actively discussed resus, escalation with appropriate patients/relatives. 
14. ALWAYS support your juniors. The FY1s on the ward may be struggling with a cannula. Be his/her go to person. Give him/her your mobile number and ask him/her to call you whenever (s)he is stuck. 
15. You will be asked by the AMU nurses to do other jobs - like discharge summaries, cannulas, bloods. Do them! Yes, this is your job. I still do this and I am a registrar! This is part of being a member of the on call team. 

Personally, I really enjoy clerking. I enjoyed it so much that I used to look forward to my clerking shifts as a SHO and as a registrar, I try my best to clerk as many patients as possible and help on AMU.