How to write a clinical review note

How to write a clinical review note
Aside from an admission note or a progress note the other type of entry in the notes worth familiarising yourself with is the clinical review note. In NSW hospitals a nurse will call the junior doctor to review their patient if any of their observations do not fall ‘between the flags’ (high ADDs score in QLD), but a nurse may ask to review the patient for other reasons such as a high blood sugar or pain.
The structure of this note will, again, depend on the person writing it. The format outlined here though is commonly used and, I think, a useful way of doing things.

1. Housekeeping, this is the same as for progress notes, see this post here. While it is important in every note you write, including the time in a clinical review note is mandatory. The position, which you write at the very top, will also read differently. Typically, it will be something like Intern after-hours or JMO after-hours.
If you are a medical student, you should write something like ‘medical student for Intern after-hours’. If you write a plan remember it must be counter-signed by a supervising doctor. Most medical students won’t be writing plans in clinical review notes, however, unless they are at a pre-internship stage or equivalent. Most medical students will simply write a clinical impression and in the plan state something like ‘will discuss with intern after hours’.

2. Format, the format is much the same as an admissions note although abbreviated at times.
- Presenting complaint (PC or ATSP)
- Admission summary/chart review
- History of Presenting Complaint (HoPC)
- Focussed examination (O/E)
- Relevant laboratory, electrocardiographic or radiographic findings
- Impression
- Plan

There are some key differences in the review note compared to, say, an admissions note which will be described here.


The presenting complaint in this setting is often referred to as asked to see patient or ATSP. It might read, for example, something as simple as, “ATSP: fall out of bed”

The admission summary includes a one or two sentence concise summary of why the patient is here. For example, “82 year old gentleman admitted for investigation and management of persistent fevers and a decline in mobility” (note that this one sentence indicates the patient’s problem is a diagnostic one, suggesting the treating team are not yet aware of the diagnosis for this patient).

The chart review goes into this a little bit further. It should make some reference to the HoPC for this admission, for example, “progressive decline in mobility over last ³/₁₂ with previous mechanical fall ²/₅₂ prior to admission”. A summary of the past medical history, “previously fit and healthy, living in full independence with wife in own home”. Some reference should be made to any key examination findings, “bilateral quadriceps wasting noted at time of admission with 4-/5 power on the right and 4+/5 on the left lower limbs”. Investigations are also relevant, e.g. “Today’s WCC (white cell count) 13 with neutrophila, UEC (urea, electrolyte and creatinine) was normal, CT Brain at time of admission showed only age-related changes”. Finally, some reference should be made to team’s plan for this patient, “awaiting MRI spine on Tuesday”.

Note that the admission summary/chart review is typically briefer than what you would find in the admission note. For clinical reviews a complete history and examination is not required, this should have been done at the time of the admission. Instead the purpose of the chart review is to familiarise yourself with the patient and focus your history and examination.

The HoPC, in this setting, may not be the same as their HoPC regarding the admission. It may be something like a blood pressure of 190/105 when the patient was actually admitted to hospital for acute back pain. In this case the acute back pain may be relevant to the clinical review HoPC (perhaps the high blood pressure is related to poorly controlled pain) or it may not be relevant at all. Similarly, the HoPC may be quite brief if you’re asked to see a patient about a blood pressure of 190/105 and they are completely asymptomatic. You would simply need to write the relevant negatives (e.g. patient denies chest pain, blurred vision, headache, or shortness of breath). Conversely, a fall out of bed requires at minimum a description of potential precipitating conditions (e.g. night time stat order of a sleeping tablet), what happened immediately prior to the fall (did they black out or lose consciousness?), injuries sustained during the fall (head injury, in particular is relevant), and how they felt after the fall (could they get up straight away, did they need help?). A falls history is quite extensive even if you’re only the after-hours doctor (often much to the distress of the patient who is already feeling insecure about their now slipping independence and who’d rather not go through it in detail).

The examination, like the history, need not be complete, this should have been done at the time of admission. It is focussed but will typically include
- Appearance – does the patient look well, unwell, critical, in pain, confused
- Vital observations, usually it’s enough to repeat the last measurements from the chart, sometimes it is more appropriate for you to measure them yourself or ask the nurse to repeat them just before you expect to arrive
- HEENT/Cardivascular/Respiratory/Abdominal/Neuro/Musculoskeletal (but note some of these systems may be omitted where they are not relevant to the call)

Relevant laboratory, electrocardiographic and radiologic investigations are also much less extensive in a clinical review setting and depend on the chart review, focussed history and examination so far. Common things that might be included here are ECG findings, finger-prick glucose, an arterial or venous blood gas recording, or a mobile chest x-ray. Sometimes you can order investigations in advance while you’re receiving a call, an ECG is a good example of this.

The impression is what you make of the patient and should not simply repeat what the nurse asked you to see the patient about. For example, “essential systolic hypertension in the elderly not requiring urgent intervention”, or “fall which reaching over bed in setting of urinary frequency, nocturia, and high dose nitrazepam”.

The plan in this setting is usefully divided up into those things you want to do immediately for the patient (e.g. repeat troponins and chest x-ray now), and those things you would like the team or more senior doctor to do when they see the patient later on (e.g. team to review anti-hypertensive medication mane (morning), or team to consider tapering night time benzodiazepine (sleeping tablets) or to handover to team mane.