Surgical Clerking Sheet Template
A comprehensive surgical clerking sheet should systematically capture patient demographics, presenting complaint with mode of presentation, complete medical/surgical/medication/allergy/social/family history, physical examination findings, diagnostic workup with differential diagnoses, pre-intervention optimization measures, and a clear timeline from presentation to intervention. 1
Patient Demographics and Identification
- Age, sex, ethnicity, and occupation must be documented in de-identified format 1, 2
- Body mass index (BMI) should be recorded as it impacts surgical risk stratification 1
- Hand dominance when relevant to the surgical condition or procedure 1
- Date and time of admission 3
Presenting Complaint
- Chief complaint in the patient's own words describing their primary symptoms 1, 2
- Mode of presentation: specify whether brought by ambulance, walked into emergency room, or referred by family physician 1, 2
- Duration and progression of symptoms 2
- Associated symptoms present or absent 4
History of Presenting Complaint
- Chronological sequence of symptom development using a timeline format 1, 2
- Delay from presentation to intervention must be documented 1
- Aggravating and relieving factors 5
- Previous episodes and their outcomes 2
Past Medical History
- All chronic medical conditions with dates of diagnosis 1, 2
- Previous surgical history with dates, procedures performed, and relevant outcomes from interventions 1, 2
- Cardiopulmonary disease status requiring preoperative optimization 6
- American Society of Anesthesiologists (ASA) Physical Status classification 6, 5
Medication History
- Current medications with specific formulation, dosage, strength, route, and duration 1, 7
- Allergies to medications with type of reaction 1, 5
- Effects of chronic medications on anesthesia care 6
- Medications to take or withhold preoperatively 5
- Anticoagulation status and management plan 1
Social History
- Smoking status with pack-years if applicable 1
- Alcohol and recreational drug use 1
- Accommodation status and living situation 1
- Walking aids or mobility devices 1
- Ability to attend postoperative visits 8
- Capacity to manage medications independently 8
Family History
- Relevant genetic information when applicable 1, 2
- Family history of surgical complications or anesthetic problems 6
Review of Systems
- Systematic review of relevant body systems based on presenting complaint 4
- Cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, musculoskeletal, and endocrine systems 6
- Barriers to communication including language and hearing impairment 8
Physical Examination
- Vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation 5
- General appearance and level of distress 2
- Systematic examination of relevant body systems with specific findings 1, 2
- Skin integrity assessment 5
- Patient's ability to cooperate and position for surgery 8
Diagnostic Assessment
- Physical examination findings 1, 2
- Laboratory testing results: complete blood count, metabolic panel, coagulation studies 1, 2
- Radiological imaging: X-rays, CT, MRI, ultrasound with specific findings 1, 2
- Electrocardiogram and chest radiograph when indicated 6, 5
- Histopathology results when available 1
Diagnostic Reasoning
- Differential diagnoses considered with rationale for each 1, 2
- Diagnostic challenges encountered: access, financial, or cultural barriers 1
- Prognostic characteristics: tumor staging for malignancies or genetic condition classification 1, 2
Pre-Intervention Optimization
- Patient-specific optimization measures: treating hypothermia, hypovolemia, hypotension 1
- Management of sepsis if present 1
- Correction of coagulopathy 1
- Optimization of cardiopulmonary disease 6
- Nothing-by-mouth (NPO) status and timing 6, 5
- Risk of acid aspiration assessment 6
Planned Intervention
- Type of intervention: pharmacologic, surgical, physiotherapy, psychological, preventive 1
- Rationale for treatment choice 1, 8
- Concurrent treatments planned: antibiotics, analgesia, anti-emetics, venous thromboembolism prophylaxis 1
- Anesthesia plan 1
- Patient positioning requirements 1
- Special equipment needed: tourniquet, specific surgical devices with manufacturer and model 1
Consent and Patient Education
- Informed consent obtained with documentation 9
- Procedure explained in lay terms avoiding medical jargon 8
- Patient anxieties addressed 8
- Postoperative instructions provided: catheter care, dressing changes, activity restrictions 5
- Expected postoperative course 5
Common Pitfalls to Avoid
- Incomplete medication dosages: Research shows less than half of medication dosages were recorded before standardized proformas were implemented 7
- Missing height and weight: These showed the most significant improvement with proforma use (p < 0.01) 3
- Inadequate investigation documentation: This was significantly improved with structured clerking sheets (p < 0.05) 3
- Non-chronological presentation: Presenting information out of sequence confuses subsequent care teams 2
- Failure to document delays: Time from presentation to intervention impacts outcomes and must be recorded 1, 2
The use of a standardized surgical clerking proforma significantly improves data capture compared to freehand methods, with 5 of 17 key criteria showing significant improvement and healthcare professionals requiring less time to revisit archived notes (p < 0.05) 3. This structured approach ensures comprehensive patient assessment while reducing the risk of missing critical information that impacts surgical outcomes and patient safety 7, 3.