Clerking

• Airway
  • Any issues:
• Breathing
  • Respiratory rate:
  • SpO₂ (on air vs oxygen):
  • Work of breathing (accessory muscles, tracheal tug):
  • Chest expansion symmetry:
  • Auscultation (wheeze, crackles, absent sounds):
• Circulation
  • Heart rate, blood pressure:
  • Peripheral perfusion (CRT, temperature of extremities):
  • Presence of oedema:
  • Cardiac auscultation (murmur, added sounds):
• Disability
  • ACVPU:
  • Capillary blood glucose:
  • Pupils (size/reactivity):
  • Signs of confusion/delirium:
• Exposure
  • Temperature:
  • Rash, wounds, pressure areas:
  • Hydration status (dry mucosa, skin turgor):

3. Respiratory-Focused Checks (key for most admissions)

• Oxygen requirement:
  • On air vs oxygen (flow rate/device)
• Target saturations documented (e.g. 88–92% vs 94–98%)
• Peak flow / spirometry (if relevant)
• Cough:
  • Dry vs productive
  • Sputum colour/volume
• Risk factors:
  • Smoking status
  • Aspiration risk

4. Cardiovascular Checks

• Fluid status assessment:
  • JVP
  • Peripheral oedema
  • Mucous membranes
• Signs of heart failure vs hypovolaemia
• Peripheral pulses (presence, symmetry)

5. Neurological & Cognitive Assessment

• Baseline cognition:
  • Confusion? Delirium screen (e.g. 4AT if available)
• Focal neurology:
  • Limb weakness, speech, coordination
• Falls risk:
  • Previous falls, gait stability

6. Medication & Compliance Review (high-yield safety area)

Current Prescribed Medications

• Confirm:
  • Name, dose, frequency
  • Indication

Key Compliance Checks

• Has the patient been taking medications as prescribed?
• Any recent missed doses?
• Any recent changes (GP or hospital)?

High-Risk Medications (explicitly check)

• Anticoagulants (warfarin, DOACs)
• Insulin / hypoglycaemics
• Steroids (risk of adrenal suppression)
• Opioids / sedatives
• Antibiotics (course completion)

Medication-Related Risks

• Side effects or toxicity
• Drug interactions
• Renal/hepatic dose adjustments needed

7. Fluid & Nutritional Status

• Oral intake (recent)
• Hydration status:
  • Clinical signs
• Swallow assessment needed? (aspiration risk)
• IV fluids:
  • Already prescribed? appropriate?

8. Renal & Urinary Checks

• Urine output:
  • Adequate / reduced
• Catheter present?
  • Indication + need review
• Symptoms:
  • Dysuria, retention, incontinence

10. Venous Thromboembolism (VTE) Risk

• Mobility status:
• Current anticoagulation?
• Pharmacological prophylaxis required?

11. Infection Assessment

• Sepsis screen:
  • Source identified?
• Relevant cultures taken?
• Antibiotics timing appropriate?

12. Functional Status & Mobility

• Baseline mobility:
  • Independent vs assistance required
• Current ability:
  • Able to mobilise safely?
• Falls risk intervention needed

13. Pain Assessment

• Pain score (0–10)
• Location, character
• Adequacy of current analgesia

14. Escalation & Monitoring Plan (clinical focus)

• Frequency of observations
• Oxygen targets
• Fluid plan
• Bloods/imaging required
• Any ceilings of care identified clinically