What should be included in a comprehensive clerking sheet for a patient undergoing surgery?

Comprehensive Surgical Clerking Sheet

A surgical clerking sheet should systematically document patient demographics, presenting complaint, complete medical history, physical examination findings, diagnostic workup, surgical plan with pre-intervention optimization, and postoperative care arrangements to ensure safe perioperative management and optimal outcomes.

Patient Demographics and Identification

• De-identified demographic details including age, sex, ethnicity, occupation, body mass index, and hand dominance when relevant 1
• Document the patient's mode of presentation (ambulance transport, emergency room walk-in, or physician referral) 1

Presenting Complaint and History

• Chief complaint describing the patient's primary symptoms and concerns 1, 2
• Timeline of symptoms presented chronologically, documenting any delays from presentation to intervention 1
• Past medical and surgical history with relevant outcomes from previous interventions 1
• Medication history including current medications, dosages, and known drug allergies 1
• Psychosocial history covering smoking, alcohol, recreational drug use, accommodation status, and mobility aids 1
• Family history including relevant genetic information when applicable 1

Clinical Examination Findings

• Systematic physical examination documenting all relevant findings pertinent to the surgical condition 1, 2
• Include clinical photographs where appropriate and consent has been obtained 1
• Assessment of patient's mental and physical status, particularly ability to cooperate and position for surgery 1, 3

Diagnostic Assessment

• All diagnostic methods employed including physical examination, laboratory testing, radiological imaging, and histopathology 1
• Differential diagnoses considered with reasoning for each 1
• Diagnostic challenges such as access limitations, financial constraints, or cultural barriers 1
• Prognostic characteristics when applicable (e.g., tumor staging, genetic conditions) 1
• Include relevant radiological or histopathological images 1

Pre-intervention Considerations and Optimization

• Patient-specific optimization measures such as treating hypothermia, hypovolemia, hypotension, managing sepsis, or addressing anticoagulation 1
• Assessment of coexisting medical conditions that may impact surgical safety 1
• Evaluation of communication barriers including language or hearing impairment 1, 3
• Confirmation of postoperative care arrangements including patient's ability to attend follow-up visits, medication administration capability, and transportation 1, 3

Surgical Plan and Informed Consent

• Type of intervention planned (pharmacologic, surgical, physiotherapy, psychological, preventive) with clear rationale 1
• Concurrent treatments including antibiotics, analgesia, anti-emetics, nil by mouth status, and venous thromboembolism prophylaxis 1
• Specific surgical details including planned anesthesia type, patient positioning, tourniquet use, surgical prep, sutures, devices, and whether single or multi-stage procedure 1
• Medical devices with manufacturer and model specifically documented 1
• Operator experience level including position on learning curve, specialization, and relevant training 1
• Documented informed consent after discussing risks, benefits, expected outcomes, surgical experience, and anticipated refractive/functional outcomes 1, 4
• Refractive or functional options discussed with patient (when applicable) 1

Postoperative Care Plan

• Setting of care and care provider clearly identified 1
• Specific postoperative instructions documented 1
• Follow-up schedule specifying when, where, and how (imaging, tests, clinical examination, phone call) 1
• Future surveillance requirements when applicable (e.g., imaging surveillance, clinical examinations) 1
• Pain management plan using validated pain scales at rest and on movement 3

Risk Assessment and Special Considerations

• Effect of ocular or organ-specific comorbidities on the surgical care process 1
• Assessment of concurrent conditions such as blepharoptosis that may affect outcomes or measurements 1
• Contraindications to surgery documented if present, including inability to safely undergo surgery due to medical/ocular conditions, inability to arrange appropriate postoperative care, or inability to provide informed consent 1

Common Pitfalls to Avoid

• Routine preoperative laboratory testing is not indicated in most cases, as multiple randomized trials show no reduction in complications 1, 3
• Avoid presenting information non-chronologically, as this confuses the clinical picture 2
• Ensure documented evaluation accurately reflects symptoms, findings, and indications for treatment 1
• Do not rely solely on written information - patients prefer oral communication from their surgeon (75% preference) and want to establish a trustful relationship 5
• Focus information on operation details and recovery (43.3% each) rather than exclusively on risks, as this better matches patient needs 5
• Address the gap in information about anesthesia details and OR environment, as this is frequently inadequate despite being highly valued by patients 6