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As a junior doctor, you will spend a lot of time writing out history and examination findings, so getting to grips with the basics of documentation is essential. This guide will help you decipher all the symbols, diagrams and shorthand you’re likely to come across when reading patients notes, and should hopefully provide you with a structure to effectively start clerking.
What should I use to write with?
You need to use a pen with blackink, as this is the most legible if notes are photocopied.
For every new sheet of paper your first task should be to document at least threekeyidentifiers for the relevant patient:
Date of birth
Unique patient identifier
If a patientlabel containing at least three identifiers is available, then this can be used instead of writing out the information manually.
You should indicate the patient’s currentlocation on the continuation sheet:
Beginning your entry in the notes
At this point, you should already be holding a pen with black ink and you should have ensured the continuation sheet has at least three key patient identifiers at the top.
The next documentation steps include:
1. Adding the date and time (in 24-hour format) of your entry.
2. Writing your name and role as an underlined heading.
3. Adding your entry in the notes below this heading (see the next section for details).
Documenting the history
When documenting a history, it’s important to apply a structured approach. Some people document a patient’s history as they take it, whereas others may summarise after they’ve spoken with a patient. If the sections of your documented history are in a different order to what is advised below, it doesn’t matter too much, just make sure you have clear headings so they’re easy to spot. Some people also find it easier to write out all the headings before they start – but you need to make sure you give yourself enough room to include all the relevant details.
Presenting complaint (PC)
The presenting complaint should be a few words describing the specific issue the patient has presented with (e.g. “chest pain”).
Make this short and to the point, there is space in the next section to expand further.
History of presenting complaint (HPC)
This section allows you to expand on the presenting complaint.
If the symptom is some kind of pain you might use the SOCRATES structure to gather more details about it:
Site: clarify the location of the pain (e.g. central chest).
Onset: determine if the pain has come on suddenly or gradually.
Character: assess the type of pain (e.g. burning, sharp or aching in nature).
Radiation: ask if the pain moves anywhere else (e.g. radiation to the arm from the chest in myocardial infarction).
Associated symptoms: ask about other symptoms which are associated with the pain (e.g. fever, shortness of breath)
Time course: clarify the duration of the pain (e.g. hours, days, weeks or months).
Exacerbating/relieving factors: ask if anything makes the pain better or worse.
Severity: assess the patient’s subjective experience of the pain’s severity on a scale of 0-10.
Past medical and surgical history (PMH)
The past medical and surgical history section is where you document any medicalconditions the patient is known to have, any significanthospitaladmissions and any surgicalhistory (e.g. operations/procedures).
Drug history (DHx)
This drughistory section is where you document:
Medications the patient is currently prescribed
Medications the patient is buying over the counter (often referred to as ‘OTC’)
Any compliance issues (e.g. if the patient is prescribed something but actually has chosen not to take it)
Family history (FHx)
The familyhistory section is where you document any diseases that runin a patient’s family (generally the focus should be on first-degree relatives).
Drawing out a familytree can be useful to identify patterns of inheritance if the disease is genetic (see below).
Social history (SHx)
The socialhistory section is where you document the various social aspects of the patient’s life that may be relevant to their condition (e.g. health risk factors) and their safety at home.
Topics can include:
Who the patient lives with
Details of the patients home (e.g. whether they have stairs)
Recreational drug use
Systems review (SR)
A systemsreview involves screening for symptoms in other body systems which may or may not relate to their presenting complaint. It may be useful to start at the top of the body and move down, or you may have your own structure, do whatever works best for you.
You’re probably thinking – all this writing is going to take forever, there must be a better way. Some common abbreviations will help, but in general, you just get quicker at writing (this may be why doctors have such terrible handwriting…).
There are a lot of abbreviations, but there will always be some variation, especially with acronyms. To be as clear as possible, always write it out in full the first time with the acronym in brackets.
PC = Presenting complaint
HPC = History of presenting complaint
PMHx = Past medical history
SR = Systems review
DHx = Drug history
FHx = Family history
SHx = Social history
Number of days = number of days/7 – (e.g. 3/7 = 3 days)
Number of weeks = number of weeks/52 – (e.g. 4/52 = 4 weeks)
Number of hours = Xº – (e.g. 8º = 8 hours)
Common abbreviations used for medications
OD = Once daily
BD = Twice daily
TDS = Three times daily
QDS = Four times daily
PRN = As required
SC = Subcutaneous
IM = Intramuscular
IV = Intravenous
Family tree symbols
Symbols commonly used when drawing a familytree are shown below.
Documenting the clinical examination
On examination (O/E)
Start by documenting your general inspection (e.g. “The patient was laid on the bed and appeared to be in significant pain”).
This is where you document the patient’s current observations/vital signs (e.g. BP/Pulse/Respiratory rate/Oxygen saturation/Temperature).
If the patient’s fluid balance is being monitored write down the input (drinking/IV/NG) and output (urine/stools/drains) that has been measured.
Focused clinical examination findings
Here you can document the focused system examinations you have performed, with the associated findings.
Examples of focused system examinations include:
Cardiovascular examination (CVS)
Respiratory examination (Resp)
Gastrointestinal examination (G.I.)
Neurological examination (Neuro)
Some common abbreviations used when documenting clinical examination include:
O/E = On examination
BP = Blood pressure
RR = Respiratory rate
Sats = Oxygen saturation
RA = Room air (when placed next to oxygen saturation)
I + II + 0 = Heart sounds 1 and 2 heard, with no added sounds
II + II + I = Heart sounds 1 and 2 heard, with an additional sound (e.g. murmur)
BS = Bowel sounds
RUL/LUL = Right upper limb/Left upper limb
RLL/LLL = Right lower limb/Left lower limb
CN = Cranial nerve (usually followed by a number e.g. CN 1)
Below are some common diagrams used when documenting clinical examination. You should avoid relying purely on diagrams to document your findings as these can be sometimes misinterpreted. Ideally, you should write out your findings beside a diagram to avoid misinterpretation. If you can’t draw something, then don’t, it’s much better to describe your findings in writing if this is the case.
Documenting the diagnosis/differential diagnosis
In this section of the clerking, you need to document a diagnosis or suggest a differential diagnosis.
Most of the time when you clerk a patient you won’t have a confirmed diagnosis and therefore you’ll need to document some possible differential diagnoses.
The symbol for a diagnosis is a singulartriangle.
The symbol for differentialdiagnosis is twotriangles next to each other.
Documenting the management plan
In this section, you need to document your plan in the form of a list.
This makes it clear to others reading the notes which investigations are underway and what interventions are planned.
Completing the entry in the notes
At the end of your entry to need to include the following:
Your full name
Your grade/role (e.g. Medical student/F2/Respiratory Registrar)
Your professional registration number (e.g. GMC number)
Your contact number (e.g. phone/bleep)
Royal College of Physicians. General medical record-keeping standards. Available from: [LINK].