Ikaneng Yingwane, student ambassador at Sefako Makgatho Health Sciences, shares advice on clerking a patient when working alone. 

______

As a medical student, clerking a patient alone is going to be a regular occurrence for you. It can be a daunting experience especially if it's your first time. However, with the right approach and mindset, it can be a valuable learning opportunity that helps you develop essential skills in patient assessment and communication.

Before entering the patient's room, ensure you have all the necessary equipment, such as a stethoscope, pen, and paper. Review the patient's medical chart and familiarise yourself with their medical history, current condition, and any ongoing treatments. This will help you feel more confident and prepared for the encounter.

When entering the patient's room, introduce yourself clearly and politely, stating your name, role as a medical student, and the purpose of the visit. Shake hands firmly and make eye contact to establish a rapport with the patient. Be respectful of their privacy and personal space, and ensure the curtains are drawn and the door is closed if necessary (remember to always gain consent before proceeding with any part of your patient clerking!)

Take a systematic and thorough approach to taking the patient's history. Start with open-ended questions to allow the patient to share their concerns and symptoms. Use active listening skills, such as maintaining eye contact and nodding, to show you are engaged and interested. Clarify any points you don't understand and avoid interrupting or finishing the patient's sentences.

Conduct a focused physical examination relevant to the patient's presenting complaint. Be respectful and courteous, explaining each step of the examination and seeking permission before proceeding. Use appropriate draping and always maintain patient modesty.

After the encounter, document the patient's history, examination findings, and any investigations or treatments in their medical chart. Ensure your handwriting is legible, and your notes are concise and accurate. Include any relevant positive or negative findings, and avoid using abbreviations or jargon.

After clerking the patient, present your findings to the healthcare team. Be clear and concise, highlighting any significant findings or concerns. Be open to feedback and questions from the team and use this as an opportunity to learn and improve.

Remember to maintain patient confidentiality at all times, avoiding discussions about the patient in public areas or with unauthorised personnel. Respect the patient's autonomy and dignity, and avoid making assumptions or judgments based on their background or condition.

Don't be afraid to seek help or clarification if you're unsure about any aspect of the patient's care. Consult with your supervisor or the healthcare team if you need guidance or support.

In conclusion, clerking a patient alone as a medical student requires a professional and systematic approach. By preparing thoroughly, introducing yourself and establishing rapport, taking a thorough history, performing a focused physical examination, documenting accurately, communicating with the healthcare team, maintaining patient confidentiality and respect, and seeking help when needed, you can conduct yourself effectively and provide high-quality patient care. Remember, this experience is an opportunity to learn and develop essential skills that will benefit you throughout your medical career. Embrace it with enthusiasm and dedication.

______

To read more student articles like this visit our student hub.