PILOT Version 3

SURGICAL AND TRAUMA CLERKING PROFORMA

Presenting Complaint: History of presenting complaint

Date: Time: Admitting Consultant: This proforma is intended as a labour saving device only. It is neither complete nor universally applicable and does NOT absolve you from ANY responsibility for taking and recording an accurate history and examination using as much free text as required

Emergency surgical admission

Surname: __________________________ First name: _________________________ Hospital Number : ___________________ DOB: ____________ Age: _________ Ward: ________ Cons: _________

Admitted From Own home / sheltered O Residential care O Nursing home O Long term care hospital O Rehabilitation Unit O Acute Hospital O Already in hospital O Other O Unknown O

PILOT Version 3

Past Medical History (tick if present) BP O MI O AF O COPD O Asthma O Diabetes O TB O RF O Stroke O Epilepsy O DVT/PE O Jaundice O Thyroid O

Family History: Social History Smoking: Never O Ex O Current O pack years Alcohol: Non O Ex O Current intake: units pw

Street drugs:

Systems Review (tick if present) CVS: Chest Pain O SOB O Orthopnoea O PND O Oedema O Palpitations O Claudication O RS: Cough O Sputum O Haemoptysis O Wheeze O GIT: Abdo pain O Nausea O Vomit O Diarrhoea O Constipation O PR blood O Jaundice O GUM: Frequency O Dysuria O Nocturia O Haematuria O Prostatism O Incontinence O CNS: Headaches O Fits / Faints / Funny turns O Dizziness O Visual Sx O Hearing Sx O

Walking ability Walks without aids O Walks with one aid O Walks with two aids or frame O Wheelchair / Bedbound O Unknown O

PILOT Version 3

Drug History Allergies? No O Yes O Drug/item Allergy/hypersensitivity

Does the patient use a dosette box? No O Yes O

#Information Source (tick all that apply) S1 S2 S1 S2 Patient / Carer GP letter GP surgery contacted Repeat prescription Brought medicines from home Previous TTA / Chart (dated ___/___/___) Nursing home records Unable to obtain medication history GP printout (Reason: ___________________________________________) Other (Specify: _________________________)

Medicines (All medications to be checked with two# sources within one working day of admission. When clerking tick which source(s) S1 used.)

Medicines on admission. Include all medicines (eg patches, inhalers, creams, drops) plus any over-the-counter medicines and herbal or vitamin

products. Pat

ient

s

own

drug

s Medicines prescribed on

in-patient chart (tick which apply)

* Comments (Please record any reason for change or stopping)

Medicine Name

Dos

e

Rou

te

Freq

uenc

y

Tick

if

brou

ght i

n P

resc

riptio

n co

ntin

ued

Pre

scrip

tion

chan

ged

*

Not

pre

scrib

ed

or s

topp

ed *

Any queries re: medication list above? (Tick when resolved)

Surname: __________________________ First name: _________________________ Hospital Number : ___________________ DOB: ____________ Age: _________ Ward: ________ Cons: _________

PILOT Version 3

Examination Findings Jaundice Y / N Anaemia Y / N Clubbing Y / N Cyanosis Y / N Oedema Y / N Lymphadenopathy Y / N Hydration status: . Temperature: C

Oxygen sat: on % Oxygen GCS: / 15 or A V P U

Cardiovascular Blood Pressure: / mmHg Pulse: JVP: Heart Sounds: Respiratory Rate: per min Abdomen PR:

Eyes Best Motor Best Verbal Open Spontaneously 4O Obeys Commands 6O Orientated 5O Open to speech 3O Localises Pain 5O Confused 4O Open to pain 2O Flexion withdrawal 4O Inappropriate words 3O Never open 1O Decerebrate flexion 3O Inappropriate sounds 2O Decerebrate extension 2O Silent 1O No Movement 1O

PILOT Version 3

MUSCULOSKELETAL/ NERVOUS SYSTEM: Cranial nerves: Peripheral nerves:

Left Upper Right Upper Left Lower Right Lower

Tone Power / 5 / 5 / 5 / 5

Reflexes Sensation Coordination

PR: Anal tone / squeeze: Anal sensation: BODY MAP (eg record fractures, abrasions, lacerations, bruising, sensory deficits)

Surname: __________________________ First name: _________________________ Hospital Number : ___________________ DOB: ____________________________ Ward: ________ Cons: _________

PILOT Version 3

INVESTIGATIONS tick those ordered (for results see serial data sheet)

ECG Comments:

Radiology Comments:

Differential Diagnoses and Plan

SIGNED: NAME: POSITION: BLEEP:

Blood Other FBC O Urine dipstick (see below) O U + Es O -HCG O LFT O MSU O CRP O ECG O Clotting O CXR O Amylase O AXR O LDH O Musculoskeletal XR O TFT O USS O Glucose O CT / MRI O Calcium O ABG (see below) O Group and Save O Other (specify below) O Other: (specify below) O

Urinalysis Results Blood Glucose pH Protein Ketones Nitrites WCC

Arterial Blood Gas Results Reference Ranges pH 7.35 7.45 pO2 >100 mmHg / >13 kPa pCO2 35 45 mmHg / 4.8 6 kPa Base XS 2 to + 2 mmol / L Lactate < 1.2 mmol / L K+ 4.0 5.3 mmol / L Hb < 11 g/dL

DVT Prophylaxis + TEDs Complete UBHT Surgical thromboprophylaxis risk assessment tool Prescribed O Not Prescribed O Reason :

PILOT Version 3

CHECK LIST:

Drug Chart O Consented and Marked O IV Fluids O Theatre booked O Analgesia O Anaesthetic review O DVT prophylaxis O NGT required? O

SENIOR REVIEW: Time /Date: SIGNED: NAME: POSITION: BLEEP:

Surname: __________________________ First name: _________________________ Hospital Number : ___________________ DOB: ____________________________ Ward: ________ Cons: _________

PILOT Version 3

POST TAKE WARD ROUND:

ACTION Nil by mouth status (please date and time if status changes strike through and set new date and time) NBM O Date: Time: Can E + D O Fit for theatre? Yes O Time: No: O Reason: JUNIOR DOCTOR SIGNED: NAME:

DNAR form MUST be completed

Preferred Ward:

Anticipated Length of Stay: O 1 day O 2 days O 3days O 4-7 days O >7 days

Frequency of observations: O hourly O 2 hourly O 4 hourly O 6 hourly

Reviewed Resuscitation Status FOR Resuscitation O DO NOT RESUSCITATE O

CONSULTANT:

Date / Time:

PILOT Version 3

SERIAL DATA

DATE

CRP