routine admissions in surgery

Last reviewed 01/2018

It is generally acknowledged that the surgical clerking is less thorough than a general medical one; it becomes a necessity when the house officer has twenty routine admissions for the next day's list, and there is a rapid development of a style of clerking much truncated in comparison to that of the student. However it is worth considering the aims of the clerking to ensure that they are fulfilled, as follows:

  • the presenting complaint is likely to have been covered in clinic. However, this may have altered or may have been poorly documented, and should be enquired after.
  • the functional or systems enquiry and past medical history are aimed at assessing fitness for anaesthetic. They also give a helpful baseline for any post operative problems, and will indicate special investigations.
  • the social history will highlight early any potential problems in the return of the patient home.
  • the examination should again assess fitness for anaesthetic; for the house surgeon this will centre on cardiovascular and respiratory systems
  • the consent may be the first time that anyone has spoken to the patient about the operation; in any case it is important to ensure that the patient is able to give informed consent
  • special investigations should reflect the scale of the operation, the age and fitness of the patient, the protocol of the hospital, and any personal preferences of the anaesthetist and surgeon