ORIGINAL ARTICLE

A customised ENT admissionsproforma and novel online‘clerking collaborative’

Ahmad A Hariri, Rachel Edmiston, Navin Mani, Simon K Lloyd

Manchester Royal Infirmary,Manchester, UK

Correspondence toAhmad A Hariri, Department ofENT, Manchester Royal Infirmary,Oxford Rd, Manchester M139WL, UK; mr.ahariri@gmail.com

Received 8 November 2015Revised 17 February 2016Accepted 17 April 2016Published Online First5 May 2016

To cite: Hariri AA,Edmiston R, Mani N, et al.BMJ Innov 2016;2:118–122.

ABSTRACTObjectives Admissions clerking proformas arecommonly used in hospitals to aid completepatient assessment. Much variation remains inthe format of these forms and they frequentlyfail to account for local-specific and specialty-specific factors. We developed and piloted theuse of a novel ear, nose and throat (ENT) clinicadmissions clerking proforma and created anational online ‘clerking collaborative’.Methods Doctors completed ‘mock clerkings’for 6 common acute ENT presentations byboth traditional methods (freehand) and usingour customised ENT diagrams. Participantswere timed throughout the process andasked to complete a feedback survey. A seniorENT clinician provided structured feedbackcomparing the quality of each type of clerking.Results 9 junior doctors participated in theexercise. 5 participants started with freehanddrawings while the remainder used ourclerking proforma first. Our customiseddiagrams provided accurate representations ofthe clinical scenarios, and were easier andfaster to complete than free drawings. Theywere also easier to interpret and bestrepresented the clinical findings comparedwith freehand clerkings. A website(MyClerking.co.uk) was created to disseminatethe clerking proforma and to allow otherclinicians to contribute improvements.Conclusions Accurate and legible clerkingsare essential to allow for continuity of careand management. This is particularlyimportant in ENT, where drawings arefrequently used to describe clinical findings.Our predrawn diagrams speed up the clerkingprocess and allow for more accurate depictionof findings. We have designed an online‘clerking collaborative’ where doctors candownload our proforma, contributeimprovements and upload their own ideas forother specialties.

INTRODUCTIONThe use of clerking proformas in theacute hospital setting has becomecommon practice. They provide a tem-plate for the clinician to ensure that anaccurate and complete assessment ismade, as well as act as a tool to improveauditing and monitoring of performance.Evidence suggests that a structured assess-ment can improve both the quality ofpatient care as well as professional per-formance.1 While there are guidelinesavailable describing what should be incor-porated into an acute admissions clerk-ing, these only provide a basic template.As such, there remains much variationregarding the layout and format of suchproformas. They frequently fail toaccount for important local factors orspecialty-specific aspects of a clerkingthat are important and often overlooked.These issues are none the more evident

than in the ear, nose and throat (ENT)specialty. While most generic clerkingproformas include areas for documentingexaminations of the respiratory, cardio-vascular, gastrointestinal and musculo-skeletal systems, there is rarely an areaspecifically for relevant ENT examin-ation. This is of importance, as the mostfrequent acute ENT presentations such astonsillitis/peritonsillar abscess, facialtrauma, neck lumps, and middle ear andvocal cord pathology are often best repre-sented using annotated drawings ratherthan written description alone.Current practice at our unit consisted

of documenting findings for acute ENTadmissions in freehand form on blank‘continuation sheets’. An audit of ourcurrent practice compared with nationalguidelines highlighted potential forimprovement to provide more complete

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documentation and handover. We therefore formu-lated a novel method for documenting examinationfindings for common ENT presentations, by creatinga customised diagram that could be annotated by theclerking doctor. We assessed satisfaction of this usinga Likert questionnaire, followed by review of eachclerking technique by a senior clinician.Our second aim was to develop a national online

‘clerking collaborative’ to combine the collectiveefforts and innovations of doctors, to formulatenational specialty-specific clerking proformas access-ible and editable by others.

METHODSA draft illustration of the head and neck region wasdesigned to allow common acute ENT clinical presen-tations to be annotated onto. Following feedbackfrom staff, the illustration was finalised and a com-puted design created (figure 1).Doctors providing acute ENT cover were asked to

participate in the study. This involved being shownimages of six common acute ENT presentations andcompleting ‘mock clerkings’ for each, using traditionalmethods (freehand) and by annotating the predrawncustomised diagram (figure 2). Participants were ran-domised to start with each of the methods and timedthroughout the process. They were then asked tocomplete a five-point Likert satisfaction survey asses-sing quality and ease of use. A senior clinician (NM)was then asked to provide structured feedback com-paring the quality of the two clerking methods. Theserelated to the professional appearance of the clerking,

legibility and ease of interpretation as well as whichclerking best represented the relevant clinical findings.A clerking proforma that incorporated the

predrawn diagram was then developed in keepingwith guidance from the Academy of Medical RoyalColleges.2 A website—MyClerking.co.uk (figure 3)—was created to nationally disseminate the clerkingproforma, and to allow other clinicians to freelycontribute ideas and improvements to the current pro-forma as well as submit proformas for other medicalspecialties.

RESULTSNine doctors participated in the exercise. All were‘senior house officers’ with from 6 to 18 months ofENT experience. Five doctors started with freehandclerkings while the remainder used the customiseddiagram first and then switched. Predrawn diagramswere faster to complete, taking an average of 167 s com-pared with 267 s for freehand drawings. All doctors feltthat the diagram appeared professional and was easy tocomplete, with 8 of the 9 doctors finding it easier touse, and 7 of the 9 preferring it to freehand drawings(figure 1). All doctors agreed that the diagram had thepotential to enhance patient care, citing ‘improved legi-bility’ and ‘more accurate’ depiction of findings thanfreehand drawings. Two doctors preferred the freedomof freehand drawings in some clinical scenarios,however, all doctors agreed to the diagram being incor-porated into future clerking proformas.Predrawn diagrams were unanimously judged to be

easier to interpret with improved legibility, felt to bestrepresent the clinical finding and appeared most pro-fessional as assessed by the senior clinician (figure 4).

DISCUSSIONWe aimed to develop a standardised acute ENTadmis-sions clerking proforma in contrast to the currentpractice of freehand clerkings at our institution. Indoing so, we sought to pilot the use of a customiseddiagram that would aid the documentation of themost common acute ENT conditions and evaluate theattitudes of team members towards this. During devel-opment, it was recognised that the benefits of ournovel idea would be limited to one hospital site. Thisled to the idea of creating an online ‘clerking collab-orative’, where the current clerking proforma couldbe uploaded and other doctors could amend, adaptand create other customised clerkings.The study shows that, overall, predrawn diagrams

provided accurate representations of clinical scenariosand were easier to complete than freehand drawings.While no study, to our knowledge, has previouslylooked at the use of customised diagrams, this result isconsistent with previous findings, which have shownthat the use of preprinted proformas improves thequality of documentation during admission.3 4 Thereis also evidence that structured documentation

Figure 1 Customised diagram of the head and neck regionfor annotation, incorporating a diagram of the tympanicmembranes, glottis and oropharynx.

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improves legibility and thus enhances the interpret-ation of clinical records.5 6 This is supported by ourfindings, where predrawn diagrams were felt to be

easier to interpret and provided better representationof the underlying condition when compared withfreehand drawings, as assessed by the senior clinician.

Figure 2 Example of mock freehand clerking (A) and customised diagram (B) by one candidate. Acute conditions consisted of acutetonsillitis with grade 3 tonsils, right ear wedge laceration, left vocal cord lesion, left orbital cellulitis, left-sided level II neck lump andright tympanic membrane perforation.

Figure 3 MyClerking.co.uk ‘clerking collaboration’ website as viewed on a tablet.

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There are some limitations to our study that need tobe addressed. Most significantly, our small sample sizemay not be representative of the wider medical com-munity, and variations may exist with other specialties.However, the intent of this study was primarily topilot a novel method in documentation not previouslyused that can be developed further through the online‘clerking collaboration’. Following further refinement,we hope to conduct a more widespread study asses-sing use of the proforma, with a larger sample size.Furthermore, we did not examine the impact of our

clerking proforma on the quality of patient care anddid not assess whether it correlated with improvedpatient outcomes. This was not within the scope ofthe study and, in any case, previous papers havesuggested that the introduction of proformas canimprove communication and the quality of patientcare,7–11 and that, conversely, poor-quality documen-tation is associated with negative patientoutcomes.12 13

Overall, the customised diagram was well receivedin the department and felt to be intuitive to use, andallowed for adequate documentation of the acuteENT presentations trialled in this study. Undoubtedly,the diagram is better suited to some conditions thanothers. In particular, level I and II neck lumps aremore difficult to document owing to their position.As such, while the diagram does not completely elim-inate the need for freehand drawings or descriptive

text in some cases, it provides a template forillustrations.Interestingly, while most doctors preferred using the

predrawn clerking, 2 of the 9 doctors surveyed in ourstudy preferred freehand clerkings despite acknow-ledging that they were slower and would generally bemore difficult to interpret. This is in keeping withother studies having shown that while doctors over-whelmingly prefer the use of clerking proformas14 asmall proportion remain concerned that it may limitfree expression.15 However, as more hospitals movetowards Electronic Patient Records (EPRs), where itwill become more difficult to draw freehand, we feelthat an electronic version of our drawing could beannotated on a tablet with relative ease allowing moreflexibility and free expression.Development of proformas often relies heavily on

the initiative of healthcare professionals to audit prac-tice and introduce change. While this is commend-able, the scope of such changes often remains limitedto one hospital or trust. With standards of medicalrecord keeping constantly changing, there is also needfor continuous review and update of such implemen-tations. At present, this would require a considerableamount of individual effort and needless repetition. Aunified approach that harnesses the knowledge andwork of all doctors to produce open source clerkingproformas would increase productivity and efficiency,and allow for continued development in keeping with

Figure 4 Feedback survey responses by doctors undergoing the exercise (n=9).

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latest standards. Our online ‘clerking collaborative’facilitates this combined approach and we invitereaders to contribute to this open project.In summary, accurate and legible admission clerk-

ings are essential across all specialties to allow for con-tinuity of care and management. Our predrawndiagrams speed up the clerking process while beingmore legible and easier to interpret. We have designedan online ‘clerking collaborative’ where doctors candownload our proforma, contribute improvementsand upload their own customised forms for otherspecialties.

Contributors AAH, RE and NM helped with the conceptionand design of the study, interpretation of data and drafting ofthe manuscript. SKL helped with study conception and criticalrevision of the manuscript. All the authors helped with revisionof the manuscript and then gave final approval of the version tobe published. AAH is responsible for the overall integrity of thecontent.

Competing interests None declared.

Provenance and peer review Not commissioned; externallypeer reviewed.

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