Taking On the Take: How to Upgrade Your Clerking Game

The foundation of an effective patient admission lies in meticulous and precise clerking. With the increasing complexity of patients on the medical take, doctors must continuously refine their clerking skills. The admission clerking is often the only time during an admission that a patient is comprehensively reviewed so it is vital that it is done right. Missing out key details can cause all sort of mischief down the line and conversely a great clerking can sometimes save hours worth of unnecessary investigations and referrals if done right.

The following are a series of tips and tricks which the author has learned through his years of (in)experience. This guide provides an overview of good practices in admission clerking, aimed at enhancing your proficiency to make your consultant very happy on the post-take ward round.

As always, this is an opinion piece and does not constitute medical advice. If in doubt, please ask a suitably qualified doctor.

Keep the History Thorough but Succinct

Effective history-taking is the cornerstone of accurate diagnosis. Ensure your history is comprehensive yet concise. It is sometimes tempting to want to write as much detail as possible, but this isn't always needed; remember someone will have to read over what you have found and probably won't appreciate an essay!

• Presenting Complaint: Clearly state the primary reason for the patient's admission as a headline, e.g. 75F a/w cough & SoB x 5/7
  • The patient may not always be clear on this; sometimes they weren't the one who called the ambulance or they have become a bit muddled having told this story to at least 2 other healthcare professionals by this point.
  • It's important to be specific as to what the initial problem was; if not clear, go back to the ED notes or even the ambulance notes because these can be a goldmine of information that the patient may not volunteer themselves.
• History of Present Complaint: Detail the chronological order of symptoms, focusing on onset, duration, and intensity. It is probably best to present these as a set of bullet points rather than prose.
• Review of Systems: Always include a systematic review to identify any additional symptoms that may be relevant to the patient's condition. This is normally the kicker where your consultant asks about something and you look like a bit of a plank for not picking up on this yourself.
• You are the Historian: as the old saying goes, the historian is the one who takes the history. The patient therefore cannot be a 'poor historian'. If you can't get a good enough history from the patient, you need to look elsewhere, such as a collateral or ambulance notes.

Dig Deep into Past Medical History

Understanding a patient's past medical history is crucial for informed decision-making. As seemingly simple as it may appear, this is not just a case of listing down every diagnosis on their GP record and leaving it at that. Chronic diseases have significant impact on how we manage acute illness, so this needs to be factored into the admission.

If possible, it is important to read at least the latest letters from any outpatient clinics they have attended.

For each and every chronic disease that patient has, consider the following questions:

1. When, how and by whom was it diagnosed?

• You can probably be more confident if a patient has been diagnosed with COPD by the Professor of Respiratory Medicine at the Brompton as opposed to the fortune teller at the fairground who read it in their tealeaves.
• Chronic diseases can sometimes be misdiagnosed and this needs to be considered, e.g. maybe the irritable bowel syndrome was in fact a manifestation of the hypothyroidism you have just picked up on. Clever you!

2. How bad is it?

• It's very useful if one can quantify a patient's chronic disease function, for example, the most recent HbA1c if they're diabetic, the last echo report for a patient with heart failure, the latest lung function tests on a respiratory patient.
• This will likely highlight issues which can be worked on during the admission evening if not directly related to their acute illness, e.g. review by the diabetic nurse if their sugars are poorly controlled.
• Always ask the patient how they manage with their condition; often they may be struggling!

3. What is the ongoing management plan (if any)?

• Critical when deciding what to do with their medication regime in hospital or whether referral is required. For example, if 96-year-old Betty has already been seen by the orthopaedic surgeons for her arthritic hip and told that she is not fit for an operation, they probably won't appreciate a call about her ongoing hip pain if they've made the decision not to operate before.
• For cancer patients especially, always establish what their latest stage is, treatment they have had and when, as this can can impact upon the acute illness. Be sure to understand whether the treatment aim is curative or palliative. And always remember that just because they've had the 'all clear' doesn't mean it can't come back…
• Don't forget that some chronic diseases, especially those of an inflammatory nature, can be affected by acute illness and thus require a change in management during the admission.

Be Mindful of Medications

A detailed medication history is vital for identifying potential drug interactions and compliance issues:

• Current Medications: List all medications, including dosage and frequency. It's best practice to cross-check this with the patient, especially if they have their medications with them or a recent prescription; GP records are often wrong!
• Compliance: Assess the patient's actual adherence to prescribed treatments.
• Allergies and Intolerances: Investigate the nature and severity of any reported allergic reactions or intolerances.
• Interactions: Always check for potential drug-drug interactions when prescribing new medications for an acute illness in patients with chronic conditions e.g. stop the statins with clarithromycin, hold the metformin and dapagliflozin, stop the nephrotoxins etc.
• Consider Deprescribing: a hospital admission is an excellent opportunity to review the need for medications especially in those with polypharmacy. Is 96-year-old Betty really going to benefit from her statins or are they just there to give her a myopathy?

Assess Social History and Frailty

Social determinants of health play a significant role in patient management, especially in older patients. Ensure to always document:

• Living Situation: Document the patient's living arrangements and support systems.
• Occupational History: Note any occupational hazards or exposures.
• Mobility and Exercise Tolerance: Document if aid is require to mobilise and how far the patient can get; the latter is especially important if considering ICU admission.
• Clinical Frailty Score: Always calculate this to evaluate the patient's frailty and guide treatment decisions and predict outcomes.
• Cognition: Check for any new changes in cognition that may require addressing. Also consider the implications this may have on capacity.

Conduct a Thorough Examination

A comprehensive physical examination is essential for identifying clinical signs that support your differential diagnosis:

• AMTS: Often missed but critical in all patients over 65 to identify delirium.
• Systematic Examination: Perform a detailed examination, focusing on areas pertinent to the patient's presenting complaint. This doesn't mean you need to examine every system, but consider what might factor into your diagnoses. Consider what pertinent positive or negative findings might change your impression.
• Signs of Decompensation: The most important signs not to miss are those that indicate an acute deterioration in the patient's health. For example, in a patient with liver disease, you might be forgiven for missing a solitary spider naevus in a skin fold but you'll look quite sheepish if you don't pick up on the obvious asterixis.
• Fluid Status: Often neglected, assess for signs of dehydration or fluid overload. In the author's opinion no clerking is complete without assessing the JVP! Most patients are very dry and this is a key point to factor into your management plan.
• Beware the Bandages: Dressings are fantastic at hiding away all sorts of nastiness. Make sure you inspect under every one. If you assume that each and every bandage is concealing a necrotic festering wound until proven otherwise, you're unlikely to miss anything.
• Never Overlook Trauma: a brief musculoskeletal survey is critical in all patients with falls and collapses. Don't just assume there are no injuries because ED have seen them already. We've all heard the horror stories of patients who have been lying on a #NoF for 3 days because it's only when the physio has tried to mobilise them they've found the obviously wonky leg that the patient hasn't complained about because they've delirious.

Complete Basic Investigations

Ensure that all essential investigations are promptly conducted and documented. This should not be left written in the plan to do later because it wasn't done by ED. Just get them done; the clerking isn't complete without them. By 'basic', the author is referring to:

• Blood Tests (FBC, U&E, LFTs etc.): Obtain baseline bloodwork for assessment.
• Chest X-Ray (CXR): Evaluate for any respiratory or cardiac pathology.
• Electrocardiogram (ECG): Rule out any cardiac abnormalities.

Once performed, then consider whether or not further investigations are required to inform immediate management.

Don't Neglect Previous Investigations

Previous investigations can offer pivotal insights that significantly impact patient management and diagnostic accuracy. For instance, if a recent coronary angiogram was clear, the likelihood of an Acute Coronary Syndrome (ACS) diminishes significantly.

Similarly, when evaluating for infections, a detailed review of past microbiology results is indispensable in the patient with suspected infection. If the patient is colonised with a highly resistant organism, this information can guide the selection of appropriate empirical therapy, circumventing ineffective treatments and reducing the risk of adverse outcomes.

Create a Problem List

Instead of focusing solely on a single diagnosis, develop a comprehensive problem list:

• Primary Issues: Identify and prioritise the patient's most pressing concerns or issues contributing to why they are in hospital.
• Secondary Issues: Note any additional problems that may impact the patient's overall health, such as electrolyte abnormalities, dehydration, frailty, polypharmacy, poor glycaemic control etc.
• Provide an Explanation: for each of the noted issues, give at least a suggestion as to why this has arisen. You should be able to explain every abnormal investigation result, or if not, have a plan to prove your theory. For example, 'hyponatraemia/hyperkalaemia - likely secondary to ACEi' would be an appropriate issue, whereas 'AKI' without further quantification would not.
• Score and Quantify: this is particularly helpful in prognostication and determining acuity. Our good friend MDCalc comes to the rescue here; nowadays there is a score for almost everything, for example:
  • Upper GI Bleed - Glasgow-Blatchford score
  • Pulmonary Embolism - PESI
  • NSTEMI - GRACE/TIMI
  • Liver Disease - Childs-Pugh score

Diagnoses to Avoid

Avoid making overly premature or unsupported diagnoses:

• Vague Terms: Avoid using non-specific terms such as "non-cardiac chest pain" without thorough further qualification.
• Assumptive Diagnoses: Ensure that all diagnoses are backed by clinical evidence and investigations.
• 'Acopia'/'Social Admission': These are both meaningless terms; the patient is clearly not coping due to their heath issues. I'm sure most previously fit people would not 'cope' at home if they were bedridden with meningococcal sepsis and as such these terms just overlook the possibility of acute issues.
• 'Mechanical Fall': Mechanics is defined as the study of the interplay between objects, motion and force. A fall is when a person [an object] goes from standing to the ground [motion] under the influence of gravity [a force]. All falls are therefore mechanical. Quad erat demonstrandum. Healthy people don't usually fall over, so this diagnosis is shorthand for 'I can't be bothered to work out why the patient fell over'.
• 'Off legs': see 'acopia'. The patient is probably 'off legs' for a very good reason; it's your job to work out why!

Exercise extreme caution with the following terms:

• 'Infection ?source': always consider, what is the evidence that this is actually an infection (inflammatory markers can be raised for all sorts of reasons) and if so, do you really have no clues at all as to the source? If there is more objective evidence, such as a pyrexia of unknown origin or bacteraemia of unknown source (both acceptable provisional diagnoses) then these require a very thorough workup.
• 'Bilateral cellulitis': there is a broad differential for hot red legs and it is very rare that both legs get infected at the same time, in a similar way to how bilateral septic arthritis of the knees would be unusual. Venous eczema is much more likely in an older patient. Don't be mislead that this is a source of infection.

Keep the Patient Comfortable

Properly documenting 'pro re nata' (PRN) medications is crucial for ensuring patient comfort and efficiency in clinical practice. When PRN medications, such as analgesics, antiemetics, and laxatives, are not promptly prescribed and clearly documented, patients may experience unnecessary discomfort while waiting for relief. After all, the patient is in hospital because they feel unwell! This delay not only impacts patient well-being but also results in the inefficient use of healthcare resources. Nurses and doctors may have to spend additional time addressing these unmet needs, time that could be devoted to other critical patient care activities. Clearly specifying the indications and dosing for PRN medications in the patient's records allows for timely administration, thus preventing any avoidable pain or distress and streamlining clinical workflow.

• Common PRNs: it would be quite difficult to criticise the appropriate prescription of analgesics, antiemetics and laxatives (exception in diarrhoea/bowel obstruction) in all patients who are admitted.
• Indications: Clearly document the indications and dosing for PRN medications. Consider here also the dosing and regularity given the patient's condition.

Hope for the Best, Plan for the Worst

It is vital to consider the possibility that this patient may become much more unwell, and an excellent clerking will consider the patient's escalation plan.

Establishing the ceiling of treatment for more frail patients at the start of the admission is crucial, particularly while the patient is still capable of making informed decisions. This preemptive action helps prevent challenging and potentially inappropriate decisions that might need to be made by an unfamiliar medical team in the middle of the night. Conversations with the patient should explore their values, preferences, and goals, focusing on what is important to them in terms of quality of life and medical interventions.

Critical aspects to consider include whether intensive care unit (ICU) admission or cardiopulmonary resuscitation (CPR) would align with the patient's wishes and overall health status. Some patients might prioritise comfort and dignity over aggressive treatments. By addressing these issues early, you can respect the patient’s autonomy and ensure their preferences are honored throughout their care. To put it another way, by not discussing this, you are denying the patient a say on what happens.

Thorough documentation of these discussions is essential. Complete the appropriate paperwork, such as a ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) form, to clearly outline the agreed-upon treatment plan. This document should provide clear guidance for all healthcare professionals involved in the patient’s care, ensuring that decisions align with the patient's wishes.

Reflect on Your Work

Reflecting on your work is a fundamental aspect of professional development and improving patient care. Staying to post-take your patients with a consultant provides an invaluable opportunity to receive direct feedback and observe different approaches to patient management, giving a deeper understanding of your own strengths and areas for improvement. By watching how experienced consultants handle complex cases—considering diagnostic pathways, treatment options, and communication strategies—you can gain fresh perspectives and refine your own clinical skills.

It is also worth trying to follow-up patients through their hospital journey as more tests are performed. Did you get the diagnosis right? How did the patient fair? All of this reflection will help to hone your clinical acumen and make your clerking at the front door better.

Conclusion

Working at the front door can be tough, but provides probably the best opportunity for hands-on learning. When first starting out, one can easily get disheartened after missing an 'obvious' diagnosis, forgetting a key question or omitting a key investigation. But over time, it can be the arena in which new doctors can prove their diagnostic acumen; each clerking is an opportunity to learn and refine techniques, making each subsequent admission a little smoother and more comprehensive. Ultimately, consistent, thorough clerking is not only about gathering information—it’s about building a foundation for the patient’s entire hospital journey, guiding treatment and helping ensure that every patient receives the highest standard of care right from the start.