Printable clerking templates
Most wards still use paper notes, so these are made to print on A4. Print a few, keep them in your file or coat pocket, and fill them in by hand. Using a structure every time means you don’t forget the important questions at 3 a.m.
Medical admission — history & examination
For medical receiving and ER admissions. Covers history, GPE, systems, vitals, investigations and plan on one page.
Medical admission — history & examination Attendant/informant: ____________
Name
Age / Sex
MR / Reg. no.
Ward / Bed
Unit / Consultant
Date & time of admission
Presenting complaints (with duration)
History of presenting illness — onset, course, character, associated symptoms, what has been tried, relevant negatives
Past history — DM, HTN, IHD, TB, hepatitis B/C, asthma/COPD, CKD, previous admissions/surgery, blood transfusions
Drug history & allergies — including medicines from the medical store, injections, herbal / hakeem
Family & social history — smoking, naswar, alcohol, occupation, who looks after them
Systemic enquiry — CVS, resp, GI, GU, CNS, MSK, skin
General physical examination
PallorJaundiceCyanosisClubbingOedemaLymph nodesDehydrationJVP ↑
Pulse
BP
RR
Temp
SpO₂ (on ___)
BSR
GCS
Wt
CVS
Respiratory
Abdomen
CNS
Summary & provisional diagnosis / differentials
Investigations sent — CBC, U/C/E, LFTs, BSR, urine R/E, ECG, CXR, cultures…
Plan / orders — fluids, drugs (dose, route, frequency), monitoring, nursing instructions, who was informed (PG/SR)
Medical admission H&E — The House Job (thehousejob.com)Sign: ____________ Name: ________________ Date/Time: __________
Surgical admission — history & examination
For surgical receiving. Includes abdominal exam, diagram box and a pre-op checklist.
Surgical admission — history & examination Receiving day: ________
Name
Age / Sex
MR / Reg. no.
Ward / Bed
Unit / Consultant
Date & time of admission
Presenting complaints (with duration)
History of presenting illness — pain (SOCRATES), vomiting, bowels/flatus, fever, urinary symptoms, trauma mechanism
Past medical & surgical history — previous operations, anaesthesia problems, DM, HTN, IHD, hepatitis
Drugs, allergies, blood thinners — aspirin, clopidogrel, warfarin, DOACs; last meal (time)
Vitals
Pulse
BP
RR
Temp
SpO₂
BSR
GCS
Pain score
General examination — pallor, jaundice, dehydration, nodes
Abdomen: inspection, palpation, percussion, auscultation — tenderness, guarding, rigidity, masses, hernial orifices, bowel sounds
Diagram / local examination — mark site of pain, wound, swelling
DRE / genitalia (with chaperone)
Other systems (CVS / resp / CNS)
Provisional diagnosis & differentials
Pre-op checklist
NPO since ____IV lineCBCU/C/EPT/INRGrouping & cross-match ___ unitsHBsAg / anti-HCVECGCXRInformed consentSite markedAnaesthesia review
Plan / orders — NPO, NG, Foley, fluids, analgesia, antibiotics, DVT prophylaxis, informed PG/SR
Surgical admission H&E — The House Job (thehousejob.com)Sign: ____________ Name: ________________ Date/Time: __________
Daily progress note (SOAP)
Two ward-round entries per page. Write subjective, objective, assessment and plan every day.
Daily progress note Ward round / SOAP
Name
Age / Sex
MR no.
Bed
Diagnosis
Date / Day of admission
Time
Seen with (PG/SR/Consultant)
Pulse
BP
RR
Temp
SpO₂
BSR
Input / Output
S — how is the patient? (complaints, overnight events, attendants’ concerns)
O — examination & new results
A — assessment (problem list, improving / same / worse)
P — plan (changes to drugs, tests, referrals, discharge plan)
Date / Day of admission
Time
Seen with (PG/SR/Consultant)
Pulse
BP
RR
Temp
SpO₂
BSR
Input / Output
S — how is the patient? (complaints, overnight events, attendants’ concerns)
O — examination & new results
A — assessment (problem list, improving / same / worse)
P — plan (changes to drugs, tests, referrals, discharge plan)
Daily progress note — The House Job (thehousejob.com)Sign: ____________ Name: ________________ Date/Time: __________
Discharge summary
Diagnosis, hospital course, discharge medicines, advice and follow-up.
Discharge summary Copy for patient · copy for file
Name
Age / Sex
MR / Reg. no.
Ward / Bed
Unit / Consultant
Date & time of admission
Date of discharge
Discharged to (home / referred / LAMA)
Final diagnosis
Presenting complaint & brief hospital course
Key investigations & results
Procedures / operations (with dates)
Medicines on discharge — name, dose, how often, for how long
Advice to patient & attendants — diet, wound care, activity, warning signs to come back immediately
Follow-up: OPD / date
Tests before follow-up
Discharge summary — The House Job (thehousejob.com)Sign: ____________ Name: ________________ Date/Time: __________
Medical admission — history & examination Attendant/informant: ____________
Name
Age / Sex
MR / Reg. no.
Ward / Bed
Unit / Consultant
Date & time of admission
Presenting complaints (with duration)
History of presenting illness — onset, course, character, associated symptoms, what has been tried, relevant negatives
Past history — DM, HTN, IHD, TB, hepatitis B/C, asthma/COPD, CKD, previous admissions/surgery, blood transfusions
Drug history & allergies — including medicines from the medical store, injections, herbal / hakeem
Family & social history — smoking, naswar, alcohol, occupation, who looks after them
Systemic enquiry — CVS, resp, GI, GU, CNS, MSK, skin
General physical examination
PallorJaundiceCyanosisClubbingOedemaLymph nodesDehydrationJVP ↑
Pulse
BP
RR
Temp
SpO₂ (on ___)
BSR
GCS
Wt
CVS
Respiratory
Abdomen
CNS
Summary & provisional diagnosis / differentials
Investigations sent — CBC, U/C/E, LFTs, BSR, urine R/E, ECG, CXR, cultures…
Plan / orders — fluids, drugs (dose, route, frequency), monitoring, nursing instructions, who was informed (PG/SR)
Medical admission H&E — The House Job (thehousejob.com)Sign: ____________ Name: ________________ Date/Time: __________
Surgical admission — history & examination Receiving day: ________
Name
Age / Sex
MR / Reg. no.
Ward / Bed
Unit / Consultant
Date & time of admission
Presenting complaints (with duration)
History of presenting illness — pain (SOCRATES), vomiting, bowels/flatus, fever, urinary symptoms, trauma mechanism
Past medical & surgical history — previous operations, anaesthesia problems, DM, HTN, IHD, hepatitis
Drugs, allergies, blood thinners — aspirin, clopidogrel, warfarin, DOACs; last meal (time)
Vitals
Pulse
BP
RR
Temp
SpO₂
BSR
GCS
Pain score
General examination — pallor, jaundice, dehydration, nodes
Abdomen: inspection, palpation, percussion, auscultation — tenderness, guarding, rigidity, masses, hernial orifices, bowel sounds
Diagram / local examination — mark site of pain, wound, swelling
DRE / genitalia (with chaperone)
Other systems (CVS / resp / CNS)
Provisional diagnosis & differentials
Pre-op checklist
NPO since ____IV lineCBCU/C/EPT/INRGrouping & cross-match ___ unitsHBsAg / anti-HCVECGCXRInformed consentSite markedAnaesthesia review
Plan / orders — NPO, NG, Foley, fluids, analgesia, antibiotics, DVT prophylaxis, informed PG/SR
Surgical admission H&E — The House Job (thehousejob.com)Sign: ____________ Name: ________________ Date/Time: __________
Daily progress note Ward round / SOAP
Name
Age / Sex
MR no.
Bed
Diagnosis
Date / Day of admission
Time
Seen with (PG/SR/Consultant)
Pulse
BP
RR
Temp
SpO₂
BSR
Input / Output
S — how is the patient? (complaints, overnight events, attendants’ concerns)
O — examination & new results
A — assessment (problem list, improving / same / worse)
P — plan (changes to drugs, tests, referrals, discharge plan)
Date / Day of admission
Time
Seen with (PG/SR/Consultant)
Pulse
BP
RR
Temp
SpO₂
BSR
Input / Output
S — how is the patient? (complaints, overnight events, attendants’ concerns)
O — examination & new results
A — assessment (problem list, improving / same / worse)
P — plan (changes to drugs, tests, referrals, discharge plan)
Daily progress note — The House Job (thehousejob.com)Sign: ____________ Name: ________________ Date/Time: __________
Discharge summary Copy for patient · copy for file
Name
Age / Sex
MR / Reg. no.
Ward / Bed
Unit / Consultant
Date & time of admission
Date of discharge
Discharged to (home / referred / LAMA)
Final diagnosis
Presenting complaint & brief hospital course
Key investigations & results
Procedures / operations (with dates)
Medicines on discharge — name, dose, how often, for how long
Advice to patient & attendants — diet, wound care, activity, warning signs to come back immediately
Follow-up: OPD / date
Tests before follow-up
Discharge summary — The House Job (thehousejob.com)Sign: ____________ Name: ________________ Date/Time: __________