Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.

1. Recording your
clerking

2. Recording your
clerking
The initial clerking of a patient is
one of the most important steps
in their journey through the
hospital.
It will be reread by every team
that looks after the patient and
used as a benchmark for
measuring the progress of the
patient’s condition.
A good clerking gives the patient
the best opportunity to receive
the correct investigations and
treatment.

3. Heading
Your name, position,
location, date, time;
state clearly why the
patient is being
clerked (eg referred
from ED with chest
pain).

4. Format
Follow a logical order
setting out each section
under the headings shown
over these four pages.
If a piece of information
from a different section is
really important then write it
in the history of presenting
complaint and/or under the
social history.

5. Sources
State where you got
important information
from (eg patient,
relative (with name and
relationship), notes,
computer records).
This makes it easy to
check if the information
is of critical importance.

6. Use the notes
Don’t rely on a patient’s
account of their
previous medical
history, especially for
investigations and
results.
Try to find the official
record of key
investigations rather
than relying on another
doctor’s comments.

7. Be thorough
These pages
represent a basic
clerking; you
should record all
of the information
described on
these pages at
the very least.

8. State the
obvious
What appears
obvious now may
not be to someone
reading the notes or
on the next shift, eg
below-knee
prosthetic leg, crying
constantly.

9. Differential diagnosis
What diseases are
likely to explain the
patient’s symptoms?
What serious diseases
need to be excluded?
Make a list of these
after the examination.
Consider recording the
most critical evidence
for and against each
diagnosis.

10. Management
plan
This should be a detailed list of
the steps you will take to
diagnose and treat the
differential diagnosis.
It should be written in order of
priority.
Alongside investigations and
treatment consider nursing
measures, frequency of
observations, what to do in the
event of deterioration, referrals,
best location (eg respiratory
ward, HDU).

11. State what the
patient was
told
This prevents
confusion.
If you are not telling
the patient about a
serious illness then
state why.