11/13/24, 7\:40 PM Guide | Clerking 101

Clerking 101

Table of contents

Introduction

As a junior doctor, you will spend a lot of time writing out history and examination
documentation is essential. This guide will help you decipher all the symbols, diagrams and shorthand you’re likely to come
across when reading patients notes, and should hopefully provide you with a structure to e

Documentation basics

What should I use to write with?

You need to use a pen with black ink, as this is the most legible if notes are photocopied.

Patient details

For every new sheet of paper your
Full name
Date of birth
Unique patient identi
Home address
If a patient label containing at least three identi
manually.

Location details

You should indicate the patient's current location on the continuation sheet\:
Hospital
Ward
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Patient identi

Beginning your entry in the notes

At this point, you should already be holding a pen with black ink and you should have ensured the continuation sheet has at
least three key patient identi
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 (see the next section for details).
Documentation example
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History

When documenting a history, it's important to apply a structured approach. Some people document a patient's history as they
take it, whereas others may summarise after they've spoken with a patient. If the sections of your documented history are in a
di
spot. Some people also
yourself enough room to include all the relevant details.

Presenting complaint (PC)

The presenting complaint should be a few words describing the speci
pain").
Make this short and to the point, there is space in the next section to expand further.

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).
Radiation\: ask if the pain moves anywhere else (e.g. radiation to the arm from the chest in myocardial infarction).
Associated symptoms\: ask about other symptoms which are associated with the pain (e.g. fever, shortness of breath)
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.

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 signi

Drug history (DHx)

This drug history section is where you document\:
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)

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
Drawing out a family tree can be useful to identify patterns of inheritance if the disease is genetic (see below).

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
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Recreational drug use
Occupation

Systems review (SR)

A systems review involves screening for symptoms in other body systems which may or may not 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.

History abbreviations

You’re probably thinking – all this writing is going to take forever, there must be a better way. Some common abbreviations will
help, but in general, you just get quicker at writing (this may be why doctors have such terrible handwriting…).
There are a lot of abbreviations, but there will always be some variation, especially with acronyms. To be as clear as possible,
always write it out in full the
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)

Medication abbreviations

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

Family tree symbols

Symbols commonly used when drawing a family tree are shown below.
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Family tree symbols

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 signi

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

been measured.
If the patient's

Focused clinical examination

Here you can document the focused system examinations you have performed, with the associated
Examples of focused system examinations include\:
Cardiovascular examination (CVS)
Respiratory examination (Resp)
Gastrointestinal examination (G.I.)
Neurological examination (Neuro)

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)
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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)

Examination diagrams

Below are some common diagrams used when documenting clinical examination. You should avoid relying purely on diagrams
to document your
diagram to avoid misinterpretation. If you can't draw something, then don't, it's much better to describe your
this is the case.
Chest diagrams

Diagnosis / di

In this section of the clerking, you need to document a diagnosis or suggest a di
Most of the time when you clerk a patient you won't have a con
possible di
The symbol for a diagnosis is a singular triangle.
The symbol for di
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Diagnosis / di

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.
Management plan
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