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Clerking and post-take review 🩺
For education and revision only. Check current NICE/BNF, specialist guidance and local NHS policy before clinical use. Newly added V19 material has not received independent clinical sign-off.
A safe acute admission links the presenting physiology to an explicit differential diagnosis, actionable plan and ownership of pending results.
Initial clerking
- Identify and treat ABCDE problems first; document presenting complaint, time course, relevant negatives, past history, medications/allergies, frailty/function, social situation and clinical examination.
- Review baseline physiology, NEWS2 and high-risk medications; do ECG/blood gas/glucose as indicated rather than ordering tests indiscriminately.
- State a prioritised problem list with likely diagnosis, dangerous alternatives, outstanding tests and immediate management.
Post-take and safety
- Confirm consultant/senior plan, VTE/antibiotic/fluids/drug decisions, escalation ceiling where appropriate, and task owner/time for pending results.
- Record capacity/consent or best-interest process where relevant, contact the patient/family appropriately and include an estimated discharge pathway.
- Give a structured handover of unresolved red flags, tasks and result follow-up.
Related Makindo topics
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