The 10 most important paperworks in Clinical Clerkship

Dear incoming Junior Intern/Clinical Clerk,

Now that you've seen your name posted on the registrar's office, I'd like to congratulate you for making it to JI-ship.

Junior Internship isn't just about roaming around the hospital, seeing patients, monitoring them, and seeing them either go home or die. The most important thing, the part and parcel of JI-ship, is the tons of paperwork that are in store for each and every JI out there. That is why JI's are officially called CLINICAL CLERKS. The second word explains everything.

Clerk, the master of paperworks.

So, in preparation for your JI-ship come April 1, here are 10 important documents that you should be familiar with starting day 1:

1. Initial Summary

• This is the first document that you should accomplish, because this should be clipped in the chart within 6 hours upon admission. You should write this on the "Intern's Notes" form, which you will definitely see on your first day. There you write your patient's history and PE, all in SOAP format. Because it's "initial," this is like a rough draft of your complete database, which is explained next.

2. Complete Database

• From the word itself, this contains the whole package of your history and PE. This consists of 2 parts: the history form and the physical exam form. You fill that up based on your initial summary, wherein you try to fill in or add answers to certain questions you might not have answered during your initial summary. This should be clipped in the chart within 24 hours upon admission. 

3. Case Discussion

• This is where "the patient is like a textbook" comes in. Clipped in the chart within 24-48 hours upon admission, this contains the case of your patient that you would like to report on. From definition to treatment and prognosis, this is where you try to unravel that human textbook of yours and make a paper about it. Originally computerised, some departments might require you to write your case discussion on your Intern's Notes form.

4. Drug Charting

• This goes hand-in-hand with your Case Discussion. Also clipped in the chart within 24-48 hours upon admission, this contains the drugs of your patient prescribed to him in the hospital. It's like how you did your formulary in pharmacology: you write down the generic name, class, mode of action, indications, adverse effects, and contraindications. You can add the half-life, peak plasma time, etc., if you so wish. Bahala ka magpakatoxic!

5. Lab Flow Sheet

• Some departments, especially when you're rotating in the charity wards, will require you to clip this on your chart the moment the first lab results come in. You update that form every time a new laboratory result arrives, or if a new imaging result comes. Some residents check that sheet, and if you don't even bother making one, well you can say hello to life's big bitch slap to the face, a.k.a. demerit.

6. Monitoring Sheet

• This is where you put in your patient's vital signs monitoring and intake/output monitoring. That is one of the most looked-at sheets, because you might not know about it, but even the consultant looks at what you write on the monitoring sheet to see how their patients are doing.

7. Referral Slip

• This is the slip that you will need whenever you will refer to a different department. Departments such as Medicine, Neurology, and Surgery are big users of this slip. Here, you write the SOAP format history and PE of your patient, and along with an attached Lab Flow Sheet, you have this slip signed by your Chief Resident, and have the receiving Chief Resident see it. Once they see it, be ready to present your case. And be sure to read before referring. You don't want to ruin your day because of poor referral, trust me on that.

8. Progress Notes

• A chart essential, especially when rotating in the charity wards, this contains what has happened to your patient or your group mate's patient throughout the 24-hour duty. This is written in SOAP format. Some departments are dead strict when it comes to this, so do not forget to update your Progress Notes everyday...unless you want to be bitch-slapped (if you know what I mean).

9. Endorsement/Take-Over Notes

• Aww, and it seems like you will be moving to a new department, or maybe a new sub-rotation. If so, then this is the form that you need to make before passing the baton to the incoming JI who'll be taking care of your patient. As the outgoing JI, you make Endorsement Notes in SOAP format, and if you're the incoming JI, the same goes with the Take-Over Notes. Residents check on this, too, so be on your toes with this one.

10. Discharge/Mortality Summary (DS/MS)

• And now your patient has to say good-bye to you, either dead or alive. If so, then this is the last form that you need to clip in the chart before the patient goes home or to the morgue. This contains the components of your Complete Database, plus all laboratory and imaging results, the course in the wards, and the take-home/discharge instructions. In the charity wards, you are required to give an extra copy of the DS (without the course in the wards) to your patient for follow-up purposes. You have to have this signed by your PGI and resident. Remember: you need to have at least 25 DS/MS in order for you to be cleared by the Records Section. But, because of the big number of your batch, I'm hoping that they will decrease the requirement to less than 25.

There are still other forms that are not discussed here, but for now, these are the essential ones that you must know once you step inside the halls of the hospital.

Good luck!