Record a clinical case

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New clerking entry

Follow the sections in order and record only information relevant to your learning.

1Case and patient details

Case title Posting Ward

Age Gender Race

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Patient identifiers

Patient nameMRN

2Presenting complaint and HOPIBuild a clear timeline in the patient’s own terms.

Chief complaint HOPI summary

Structured HOPI guideThese details print on the matching lines beneath the HOPI summary.

SiteOnset CharacteristicsRadiation AssociationsTime / timing Exacerbating / alleviating factorsSeverity

3Systemic reviewSelect every relevant symptom across as many systems as needed. Selected words are underlined in the exported PDF.

System review notes

4Background historiesKeep social details relevant and non-identifying.

Past medical history Past surgical history Drug history Allergy history Family history Social history

Clerking sheet details

Optional fields mapped to the matching lines on the printable template.

Past blood transfusionMenstrual history Similar problem in familyFamilial disease OccupationMarital status Smoking historyAlcohol history Promiscuity / sexual riskRecreational drug history Travel historyOther social history

5Assessment and planConfirm clinical decisions with your supervisor and local guidelines.

Key examination findings Provisional diagnosis Differential diagnoses Investigations Management / treatment plan

6Personal learning recordAdd your own learning without identifying the patient.

Notes or useful snippets Learning imagesOptional. Add multiple JPG, PNG or WebP images. Each image is compressed and uploaded separately. Never upload an identifiable patient image. What I learnt TagsSeparate tags with commas. Review status

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