Kidd D, Stout R W
Department of Geriatric Medicine, Queen's University at Belfast, Northern Ireland, UK.
Disabil Rehabil. 1996 Apr;18(4):205-8. doi: 10.3109/09638289609166301.
In order to assess the completeness of clinical clerking, a retrospective study was made of the medical notes of 194 patients admitted with acute stroke over a 1-year period. The noting of clinical features associated with disease severity and prognosis, such as level of consciousness, proprioception, neglect, mental test score and continence was assessed. These features were rarely noted. Factors likely to influence placement following recovery were also poorly reported. In order to allow an accurate guide to stroke severity and prognosis these factors must be noted. An alternative form of clinical clerking is suggested in order to improve patient management.
