Medical clerking / best format for peers / consultants
We all cover the same information on clerking
But what’s most interesting is how we present it.
Noted clerking documentation / layout makes a huge difference.
What’s everyone’s preferred Format to make your lives easier on post take
What I think is better is rather than having BG/PMH all the way under the HPC is have it right at the top to give a good oversight initially.
So mine is something like
80M + performance status number
Referred by ED for Chest Pain ?NSTEMI
BG ( PMH summarised alongside surgical Hx)
HPC
Further expansion on social
Dhx / Allergies
Examination findings
Bloods / Ix / imaging
My thoughts / clinical reasoning
Clerking diagnosis
Plan
As an early IMT wanted to hear from seniors / consultant what you think makes good documentation / structure.
Wanting to improve
Thanks