CLERKING SHEET FOR SEMESTER 6 7 (MEDICAL)

PATIENT CLERKING SHEET FOR SEMESTER 6 & 7
STUDENT NAME:
STUDENT ID:
SEMESTER:
ROTATION:
SUPERVISOR’S NAME:

PATIENT DETAILS
INITIALS:
IC NUMBER:
HOSPITAL NUMBER:
AGE:
SEX:
DATE OF ADMISSION:
DATE OF DISCHARGE/DEATH:

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PATIENT’S HISTORY
CHIEF COMPLAINTS:
HISTORY OF PRESENTING COMPLAINTS:

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PAST MEDICAL/SURGICAL HISTORY:
FAMILY HISTORY:
SOCIAL HISTORY:
DRUG & ALLERGY HISTORY:
SYSTEMIC REVIEW:

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CLINICAL EXAMINATION FINDINGS:
VITAL SIGNS:
GENERAL PHYSICAL EXAMINATION:
EXAMINATION OF SYSTEMS:

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PROVISIONAL DIAGNOSIS WITH CLINICAL REASONS:
DIFFERENTIAL DIAGNOSES WITH CLINICAL REASONS:
IDENTIFY AND PRIORITIZE PROBLEMS:

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RELEVANT INVESTIGATIONS WITH JUSTIFICATIONS:
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COMPLETE FINAL DIAGNOSIS:
IMMEDIATE MANAGEMENT PLAN (OUTLINE RATIONALE FOR THE PLAN):
FOLLOW-UP PLAN AFTER IMMEDIATE MANAGEMENT (OUTLINE RATIONALE FOR THE PLAN):

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INPATIENT PROGRESS (SUMMARISE EACH DAY’S EVENT)
DAY 1
Query:
Answer:
DAY 2
Query:
Answer:

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DAY 3

Query:
Answer:

DAY 4

Query:
Answer:

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DISCHARGE PLAN:
MEDICATIONS ON DISCHARGE (PLEASE PROVIDE RATIONALE FOR EACH MEDICATION
PRESCRIBED)

FOLLOW-UP PLAN (INCLUDING COUNSELLING):

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LEARNING ISSUES IN RELATION TO THE 8 IMU OUTCOMES:
LEARNING ISSUE 1:

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LEARNING ISSUE 2:
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