What is a “clerking”?
A clerking is a comprehensive history and full examination of a patient taken when the patient presents to a hospital or other health care facilities. This includes initial investigation results, the team’s differential diagnoses and a management plan.
Clerking is more than mere journalism, and communication with the patient (and family, carers etc where appropriate) is very important.
A full history consists basically of the following components:
- Greeting and establishing rapport
- Biodata: name, age, sex, occupation, place of origin (tribe), place of residence, religion and denomination, marital status
- Presenting Complaint (PC)
- History of Presenting Complaint (HPC)
- Past Medical and Surgical and Psychiatric history
- Family and Social history.
- Drug and Allergy history
- Review of Systems
- Summary of history.
Some specialties like paediatrics, obstetrics & gynaecology and psychiatry have other peculiar components of the history in addition to the above. These will be included in the relevant clerking guides for each case.
This starts with a general physical examination to get an overview of the patient’s general status. Points noted include:
- General appearance: acutely or chronically ill-looking
- Afebrile/febrile (stating the temperature if abnormal)
- Cyanosed or acyanotic
- Hydration/Dehydration status
- Palpable lymphadenopathy
- Digital clubbing
- Limb oedema
System examinations then follow, examining the primarily affected system(s) first.
Then follows the final summary which will tie up information from both history and examinations to arrive at a logical working diagnosis (or diagnoses).
Appropriate investigations may then be carried out to either establish the working diagnosis or rule out closely related differentials.
How to Document Your Findings
Writing in medical notes requires you to have:
At the top of the document:
- Two patient-identifiable details on each page – name and hospital number
- Patient’s location in hospital
- The date and time you are writing
- Who you are and who the most senior person responsible for care present is
At the end of the document:
- Your signature
- Grade, e.g. 4th year medical student
- If you are writing in retrospect, state so and what time you saw the patient.
Medical documentation contains a host of abbreviations and symbols. It is important to learn the generally recognised and understood ones, and apply them when necessary. They make documentation quick and easy, and illustrate findings to other health care professionals clearly and concisely.