The “scripted” guide to patient clerking

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The below article has been reproduced from a BMJ series to help medical students make the leap to budding doctors. In this article, Richard Beasley and co-authors explain how you can improve your patient clerking skills and impress your consultant.

Undergraduate teaching of patient clerking is based primarily on the systematic and detailed elucidation of the history and clinical examination, from which a summary of the key findings is made and a differential diagnosis is developed.1-3

While this approach represents good training and a basic introduction for medical students learning the art of clinical medicine, it is insufficient for the demands of the junior doctor in hospital-based clinical practice. A more practical and problem oriented method is required, which is based on the systematic analysis and synthesis of the case (Box 1).

Box 1: Systematic approach to patient clerking
Differential diagnosis

  • Try to weight the likelihood of the differential diagnoses based on the key positive and negative features
  • Always force yourself to consider at least one alternative diagnosis, owing to the variation in presentation of even common disorders
  • Return to the history and clinical examination to elicit or confirm the key features

Risk factors

  • Consideration of risk factors for the differential diagnoses may influence their relative probabilities
  • Recognising and treating the risk factors may be as important as treating the presenting complaint

Problem list

  • Coexisting conditions may have a major impact on the presenting illness; likewise the presenting illness may influence the co-morbidities

Complications

  • The major determinants of long term outcome may be the complications of the presenting illness or concomitant conditions

Investigation

  • Investigate with judgment, undertaking only tests which are relevant to the case. Ordering the initial test is not the only responsibility; it is also necessary to obtain the results from tests that have been ordered

Severity and prognosis

  • Recognition of severity and prognosis are important determinants of management

Treatment

  • Consider the risks as well as the benefits of treatment

Evaluation

  • Can all the different aspects of the case be brought together within a single disorder or does the case need to be divided into different unrelated disorders? This is potentially the most difficult aspect of the case but is made considerably easier by consideration of the above key issues

The order of the systematic approach may vary depending on the features of the case. This approach can be recalled through use of the acronym SCRIPTED.

Using a focused approach

A practical way in which this can be achieved is to undertake an initial history and examination and then revisit key features in a more focused manner as one works through the analysis and synthesis of the case. For junior doctors, this provides a practical solution to the problems of forgetting or missing out key features of the history or examination, and not recognising the importance or relevance of these features when elicited as part of a general, rather than the focused approach. This method of patient clerking also allows the junior doctor to develop an integrated plan for the investigation and management of patients within a time frame whereby on-call commitments can be met, which may involve admitting many patients on each day on call.

Get ready for the consultant

With this approach, it should also be possible for junior doctors to answer the questions that are likely to be put to them by the consultant on the post-acute ward round (Box 2). To assist recall of this approach, the acronym SCRIPTED could be used. Over time, the junior doctor should be able to develop his or her own style, based on the principles of this prototype system, and learn how to vary its use depending on the clinical situation in which it is employed.

Box 2: Consultant questions from the case presentation
  • What do you think is the presenting diagnosis and what else do you think it could be?—Differential diagnosis
  • Why has it occurred?—Risk factors
  • What other problems does the patient have?—Problem list
  • Are there any issues relating to the presenting complaint or other problems?—Complications
  • What tests have been undertaken and what are the results?—Investigations
  • How have you managed this case?—Treatment
  • What has the patient been told in terms of outlook?—Severity and prognosis
  • Is there anything else about the case that you want to tell me?—Evaluation

 

Original authors:
Richard Beasley, General physician and professor of medicine
Geoffrey M Robinson, General physician and chief medical officer
Sarah Aldington, Senior research fellow
Medical Research Institute of New Zealand/Wellington Hospital, Wellington, New Zealand.

We gratefully acknowledge the BMJ for permission to reproduce this article.

References

  1. Epstein O, Perkin GD, Cookson V, de Bono DP, eds. Clinical examination . 3rd ed. New York: Mosby, 2003.
  2. Edwards CR, Kendall RE, Munro JF. The principles of a clinical examination. In: Munro J, Edwards CRW, eds. Macleod’s clinical examination. 9th ed. Edinburgh: Churchill Livingstone, 1995.
  3. Talley NJ, O’Connor S, eds. Clinical examination: a systemic guide to physical diagnosis. 4th ed. Oxford: Blackwell Science, 2001.

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