Writing a medical clerking proforma

We found that these clerkings frequently fell short of national record keeping standards, potentially leading to an increased risk for patients during their hospital stay. In addition, we found that junior doctors did not feel confident in clerking vascular surgery patients. A literature review found that high quality clerkings were strongly linked to improved patient safety, and that the use of a pro forma was one method to improve compliance with documentation guidelines. We devised a clerking pro forma based on national guidelines and introduced it to the department.

Writing a medical clerking proforma

While case studies cannot provide specific guidance for the management of successive patients, they are a record of clinical interactions which help us to frame questions for more rigorously designed clinical studies. Case studies also provide valuable teaching material, demonstrating both classical and unusual presentations which may confront the practitioner.

Writing a medical clerking proforma obviously, since the overwhelming majority of clinical interactions occur in the field, not in teaching or research facilities, it falls to the field practitioner to record and pass on their experiences.

However, field practitioners generally are not well-practised in writing for publication, and so may hesitate to embark on the task of carrying a case study to publication.

A Practical Guide to Clinical Medicine

These guidelines are intended to assist the relatively novice writer — practitioner or student — in efficiently navigating the relatively easy course to publication of a quality case study. Authors may decide that the particular circumstances of their case study justify digression from our recommendations.

Additional and useful resources for chiropractic case studies include: Single subject research designs.

writing a medical clerking proforma

J Can Chirop Assoc ; 35 2: J Can Chirop Assoc ; 50 2: J Can Chiropr Assoc ; 51 2: Portions of these guidelines were derived from Budgell B. Writing a biomedical research paper.

Springer Japan KK, General Instructions This set of guidelines provides both instructions and a template for the writing of case reports for publication. You might want to skip forward and take a quick look at the template now, as we will be using it as the basis for your own case study later on.

While the guidelines and template contain much detail, your finished case study should be only to 1, words in length. Therefore, you will need to write efficiently and avoid unnecessarily flowery language. After this brief introduction, the guidelines below will follow the headings of our template.

Hence, it is possible to work section by section through the template to quickly produce a first draft of your study. To begin with, however, you must have a clear sense of the value of the study which you wish to describe. Therefore, before beginning to write the study itself, you should gather all of the materials relevant to the case — clinical notes, lab reports, x-rays etc.

Another important general rule for writing case studies is to stick to the facts. A case study should be a fairly modest description of what actually happened. Speculation about underlying mechanisms of the disease process or treatment should be restrained.

Field practitioners and students are seldom well-prepared to discuss physiology or pathology. This is best left to experts in those fields. The thing of greatest value that you can provide to your colleagues is an honest record of clinical events.

Editorial or promotional remarks do not belong in a case study, no matter how great our enthusiasm. It is best to simply tell the story and let the outcome speak for itself. The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet.

They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. The two most common formats of titles are nominal and compound.

Introduction

Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing — at the very least they must be able to explain and even defend the article.

Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. If there is more than one author, one author must be identified as the corresponding author — the person whom people should contact if they have questions or comments about the study.Admissions records are essential in communicating key information regarding unwell patients and at handover of care.

We designed, implemented and evaluated the impact of a standardised surgical clerking proforma on documentation and clinician acceptability in comparison to freehand clerking.

Introduction to Orthopaedic Surgery. Medical treatment of osteopenia/osteoporosis Anti-osteoclast agents, calcium supplementation fluids and medications. Before writing for any of this standard order protocol, check with the appropriate resident on your other services. Suggested Reading Resources.

Oxford University Press | Online Resource Centre | Example patient letters and forms

The surgical admissions proforma: Does it make a difference? The Harvard community has made this clerking proforma on documentation and clinician acceptability in comparison to freehand clerking.

A Dutch study of . Jan 06,  · Sample Admission Notes for the Most Common Medical Conditions The sample notes provide most of the questions to ask while collecting patient history, the common physical findings, and the typical assessment and plan.

Therefore, the use of a standard clerking pro forma for all surgical spinal patients could be a useful tool enabling improvements in patients care and safety in keeping with General Medical Council/National Institute for Health and Care Excellence guidelines. Guidelines to the writing of case studies.

Dr. Brian These guidelines for the writing of case studies are designed to be consistent with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” referenced elsewhere in the JCCA instructions to authors. such as MeSH (Medical subject headings).

A copy of MeSH .

Clinical Notes: Sample Admission Notes for the Most Common Medical Conditions