PILOT Version 3

SURGICAL AND TRAUMA CLERKING PROFORMA

Surname: __________________________
First name: _________________________
Hospital Number : ___________________
DOB: ____________

Age: _________

Ward: ________

Cons: _________

Date:

Emergency surgical
admission

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

Presenting Complaint:
History of presenting complaint

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

O
O
O
O
O
O
O
O
O

PILOT Version 3
Past Medical History (tick if present)
BP
MI
AF
COPD
Asthma
Diabetes
TB
RF
Stroke
Epilepsy
DVT/PE
Jaundice
Thyroid

O
O
O
O
O
O
O
O
O
O
O
O
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:

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

Systems Review (tick if present)

CVS:
RS:
GIT:
GUM:
CNS:

Chest Pain O SOB O Orthopnoea O PND O Oedema O Palpitations O Claudication O

Cough O Sputum O Haemoptysis O Wheeze O
Abdo pain O Nausea O Vomit O Diarrhoea O Constipation O PR blood O Jaundice O
Frequency O Dysuria O Nocturia O Haematuria O Prostatism O Incontinence O
Headaches O Fits / Faints / Funny turns O Dizziness O Visual Sx O Hearing Sx O

O
O
O
O
O

PILOT Version 3

Surname: __________________________

Drug History
Allergies?
Drug/item

No

Yes

First name: _________________________

Hospital Number : ___________________

Allergy/hypersensitivity

Does the patient use a dosette box?

No

Yes

DOB: ____________

Age: _________

Ward: ________

Cons: _________

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

Medicines

Not prescribed
or stopped *

Prescription
changed *

prescribed on
in-patient chart
(tick which apply)

Prescription
continued

Frequency

Route

Dose

Medicine Name

Tick if
brought in

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

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

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

Information Source (tick all that apply)

S1

S2

Patient / Carer

GP surgery contacted

Brought medicines from home

Nursing home records

GP printout

Other (Specify: _________________________)

S1

S2

GP letter

Repeat prescription

Previous TTA / Chart (dated ___/___/___)

Unable to obtain medication history

(Reason: ___________________________________________)

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
Eyes
Open Spontaneously
Open to speech
Open to pain
Never open

O
3
O
2
O
1
O

Best Motor
Obeys Commands
Localises Pain
Flexion withdrawal
Decerebrate flexion
Decerebrate extension
No Movement

Cardiovascular
Blood Pressure: / mmHg
Pulse:
JVP:
Heart Sounds:

Respiratory
Rate: per min

Abdomen

PR:

O
5
O
4
O
3
O
2
O
1
O

Best Verbal
Orientated
Confused
Inappropriate words
Inappropriate sounds
Silent

O
O
3
O
2
O
1
O
4

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

PILOT Version 3

Surname: __________________________

MUSCULOSKELETAL/ NERVOUS SYSTEM:

First name: _________________________

Cranial nerves:

Hospital Number : ___________________

DOB: ____________________________
Ward: ________

Peripheral nerves:
Left Upper

Right Upper

Left Lower

Cons: _________

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)

PILOT Version 3
INVESTIGATIONS tick those ordered
(for results see serial data sheet)
Blood
FBC
U + Es
LFT
CRP
Clotting
Amylase
LDH
TFT
Glucose
Calcium
Group and Save
Other: (specify below)

Other
Urine dipstick (see below)
-HCG
MSU
ECG
CXR
AXR
Musculoskeletal XR
USS
CT / MRI
ABG (see below)
Other (specify below)

O
O
O
O
O
O
O
O
O
O
O
O

Urinalysis Results
Blood
Glucose
pH
Protein
Ketones
Nitrites
WCC

O
O
O
O
O
O
O
O
O
O
O

DVT Prophylaxis + TEDs

Complete UBHT Surgical
thromboprophylaxis risk assessment tool
Prescribed
O
Not Prescribed
O
Reason :

Arterial Blood Gas Results

pH
pO2
pCO2
Base XS
Lactate
K+
Hb

Reference Ranges
7.35 7.45
>100 mmHg / >13 kPa
35 45 mmHg / 4.8 6 kPa
2 to + 2 mmol / L
< 1.2 mmol / L
4.0 5.3 mmol / L
< 11 g/dL

ECG Comments:

Radiology Comments:

Differential Diagnoses and Plan

SIGNED:

NAME:

POSITION:

BLEEP:

PILOT Version 3

Surname: __________________________

SENIOR REVIEW:
Time /Date:

First name: _________________________

Hospital Number : ___________________
DOB: ____________________________
Ward: ________

SIGNED:

NAME:

POSITION:

Cons: _________

BLEEP:

CHECK LIST:
Drug Chart
IV Fluids
Analgesia
DVT prophylaxis

O
O
O
O

Consented and Marked

Theatre booked
Anaesthetic review
NGT required?

O
O
O
O

PILOT Version 3
POST TAKE WARD ROUND:
CONSULTANT:
Date / Time:
ACTION

Nil by mouth status (please date and time if status changes strike through and set new date and time)
NBM

Fit for theatre?

Reason:

Date:
Yes O

Time:
Time:

Can E + D O

No: O

JUNIOR DOCTOR SIGNED:

NAME:

Reviewed Resuscitation Status

FOR Resuscitation
O
DO NOT RESUSCITATE
O
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

PILOT Version 3

Surname: __________________________
First name: _________________________
Hospital Number : ___________________
DOB: ____________________________

SERIAL DATA

Ward: ________

DATE
CRP
Hb

<10mg/L
11.5-15.5g/dL

MCV

80-96 fL

WCC

4-11x10 /L

Neutrophils

1.5-7.5x10 /L

Platelets

150-400 x10 /L

Creatinine

70-120mol/L
60-100mol/L

Urea

3-7mmol/L

Sodium

135-145mmol/L

Potassium

3.5-5.0mmol/L

Calcium (correct)

2.25-2.7mmol/L

Magnesium

0.7-1.0mmol/L

Phosphate

0.85-1.4mmol/L

Bilirubin
Alk Phos

<17 mol/L
20-120 units/L

ALT

5-40 IU/L

Total Protein

62-80 g/L

Albumin

35-55 g/L

Globulin

22-36 g/L

PT
APTT

11.5-15 sec
25-37 sec

INR
Amylase

<90 IU/L

LDH
D Dimer
Troponin I

<500ng/ml
<0.04

Total Cholesterol
TSH

0.3-4 mU/L

FT4

10-24pmol/L

Glucose

<6.1 mmol/L fasting

Cons: _________