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Original article
A customised ENT admissions proforma and novel online ‘clerking collaborative’
  1. Ahmad A Hariri,
  2. Rachel Edmiston,
  3. Navin Mani,
  4. Simon K Lloyd
  1. Manchester Royal Infirmary, Manchester, UK
  1. Correspondence to Ahmad A Hariri, Department of ENT, Manchester Royal Infirmary, Oxford Rd, Manchester M13 9WL, UK; mr.ahariri{at}


Objectives Admissions clerking proformas are commonly used in hospitals to aid complete patient assessment. Much variation remains in the format of these forms and they frequently fail to account for local-specific and specialty-specific factors. We developed and piloted the use of a novel ear, nose and throat (ENT) clinic admissions clerking proforma and created a national online ‘clerking collaborative’.

Methods Doctors completed ‘mock clerkings’ for 6 common acute ENT presentations by both traditional methods (freehand) and using our customised ENT diagrams. Participants were timed throughout the process and asked to complete a feedback survey. A senior ENT clinician provided structured feedback comparing the quality of each type of clerking.

Results 9 junior doctors participated in the exercise. 5 participants started with freehand drawings while the remainder used our clerking proforma first. Our customised diagrams provided accurate representations of the clinical scenarios, and were easier and faster to complete than free drawings. They were also easier to interpret and best represented the clinical findings compared with freehand clerkings. A website ( was created to disseminate the clerking proforma and to allow other clinicians to contribute improvements.

Conclusions Accurate and legible clerkings are essential to allow for continuity of care and management. This is particularly important in ENT, where drawings are frequently used to describe clinical findings. Our predrawn diagrams speed up the clerking process and allow for more accurate depiction of findings. We have designed an online ‘clerking collaborative’ where doctors can download our proforma, contribute improvements and upload their own ideas for other specialties.

  • Accessible
  • Assistive Technology
  • Otolaryngology

Statistics from


The use of clerking proformas in the acute hospital setting has become common practice. They provide a template for the clinician to ensure that an accurate and complete assessment is made, as well as act as a tool to improve auditing and monitoring of performance. Evidence suggests that a structured assessment can improve both the quality of patient care as well as professional performance.1 While there are guidelines available describing what should be incorporated into an acute admissions clerking, these only provide a basic template. As such, there remains much variation regarding the layout and format of such proformas. They frequently fail to account for important local factors or specialty-specific aspects of a clerking that are important and often overlooked.

These issues are none the more evident than in the ear, nose and throat (ENT) specialty. While most generic clerking proformas include areas for documenting examinations of the respiratory, cardiovascular, gastrointestinal and musculoskeletal systems, there is rarely an area specifically for relevant ENT examination. This is of importance, as the most frequent acute ENT presentations such as tonsillitis/peritonsillar abscess, facial trauma, neck lumps, and middle ear and vocal cord pathology are often best represented using annotated drawings rather than written description alone.

Current practice at our unit consisted of documenting findings for acute ENT admissions in freehand form on blank ‘continuation sheets’. An audit of our current practice compared with national guidelines highlighted potential for improvement to provide more complete documentation and handover. We therefore formulated a novel method for documenting examination findings for common ENT presentations, by creating a customised diagram that could be annotated by the clerking doctor. We assessed satisfaction of this using a Likert questionnaire, followed by review of each clerking technique by a senior clinician.

Our second aim was to develop a national online ‘clerking collaborative’ to combine the collective efforts and innovations of doctors, to formulate national specialty-specific clerking proformas accessible and editable by others.


A draft illustration of the head and neck region was designed to allow common acute ENT clinical presentations to be annotated onto. Following feedback from staff, the illustration was finalised and a computed design created (figure 1).

Figure 1

Customised diagram of the head and neck region for annotation, incorporating a diagram of the tympanic membranes, glottis and oropharynx.

Doctors providing acute ENT cover were asked to participate in the study. This involved being shown images of six common acute ENT presentations and completing ‘mock clerkings’ for each, using traditional methods (freehand) and by annotating the predrawn customised diagram (figure 2). Participants were randomised to start with each of the methods and timed throughout the process. They were then asked to complete a five-point Likert satisfaction survey assessing quality and ease of use. A senior clinician (NM) was then asked to provide structured feedback comparing the quality of the two clerking methods. These related to the professional appearance of the clerking, legibility and ease of interpretation as well as which clerking best represented the relevant clinical findings.

Figure 2

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

A clerking proforma that incorporated the predrawn diagram was then developed in keeping with guidance from the Academy of Medical Royal Colleges.2 A website— (figure 3)—was created to nationally disseminate the clerking proforma, and to allow other clinicians to freely contribute ideas and improvements to the current proforma as well as submit proformas for other medical specialties.

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


Nine doctors participated in the exercise. All were ‘senior house officers’ with from 6 to 18 months of ENT experience. Five doctors started with freehand clerkings while the remainder used the customised diagram first and then switched. Predrawn diagrams were faster to complete, taking an average of 167 s compared with 267 s for freehand drawings. All doctors felt that the diagram appeared professional and was easy to complete, with 8 of the 9 doctors finding it easier to use, and 7 of the 9 preferring it to freehand drawings (figure 1). All doctors agreed that the diagram had the potential to enhance patient care, citing ‘improved legibility’ and ‘more accurate’ depiction of findings than freehand drawings. Two doctors preferred the freedom of freehand drawings in some clinical scenarios, however, all doctors agreed to the diagram being incorporated into future clerking proformas.

Predrawn diagrams were unanimously judged to be easier to interpret with improved legibility, felt to best represent the clinical finding and appeared most professional as assessed by the senior clinician (figure 4).

Figure 4

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


We aimed to develop a standardised acute ENT admissions clerking proforma in contrast to the current practice of freehand clerkings at our institution. In doing so, we sought to pilot the use of a customised diagram that would aid the documentation of the most common acute ENT conditions and evaluate the attitudes of team members towards this. During development, it was recognised that the benefits of our novel idea would be limited to one hospital site. This led to the idea of creating an online ‘clerking collaborative’, where the current clerking proforma could be uploaded and other doctors could amend, adapt and create other customised clerkings.

The study shows that, overall, predrawn diagrams provided accurate representations of clinical scenarios and were easier to complete than freehand drawings. While no study, to our knowledge, has previously looked at the use of customised diagrams, this result is consistent with previous findings, which have shown that the use of preprinted proformas improves the quality of documentation during admission.3 ,4 There is also evidence that structured documentation improves legibility and thus enhances the interpretation of clinical records.5 ,6 This is supported by our findings, where predrawn diagrams were felt to be easier to interpret and provided better representation of the underlying condition when compared with freehand drawings, as assessed by the senior clinician.

There are some limitations to our study that need to be addressed. Most significantly, our small sample size may not be representative of the wider medical community, and variations may exist with other specialties. However, the intent of this study was primarily to pilot a novel method in documentation not previously used that can be developed further through the online ‘clerking collaboration’. Following further refinement, we hope to conduct a more widespread study assessing 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 and did not assess whether it correlated with improved patient outcomes. This was not within the scope of the study and, in any case, previous papers have suggested that the introduction of proformas can improve communication and the quality of patient care,7–11 and that, conversely, poor-quality documentation is associated with negative patient outcomes.12 ,13

Overall, the customised diagram was well received in the department and felt to be intuitive to use, and allowed for adequate documentation of the acute ENT presentations trialled in this study. Undoubtedly, the diagram is better suited to some conditions than others. In particular, level I and II neck lumps are more difficult to document owing to their position. As such, while the diagram does not completely eliminate the need for freehand drawings or descriptive text in some cases, it provides a template for illustrations.

Interestingly, while most doctors preferred using the predrawn clerking, 2 of the 9 doctors surveyed in our study preferred freehand clerkings despite acknowledging that they were slower and would generally be more difficult to interpret. This is in keeping with other studies having shown that while doctors overwhelmingly prefer the use of clerking proformas14 a small proportion remain concerned that it may limit free expression.15 However, as more hospitals move towards Electronic Patient Records (EPRs), where it will become more difficult to draw freehand, we feel that an electronic version of our drawing could be annotated on a tablet with relative ease allowing more flexibility and free expression.

Development of proformas often relies heavily on the initiative of healthcare professionals to audit practice and introduce change. While this is commendable, the scope of such changes often remains limited to one hospital or trust. With standards of medical record keeping constantly changing, there is also need for continuous review and update of such implementations. At present, this would require a considerable amount of individual effort and needless repetition. A unified approach that harnesses the knowledge and work of all doctors to produce open source clerking proformas would increase productivity and efficiency, and allow for continued development in keeping with latest standards. Our online ‘clerking collaborative’ facilitates this combined approach and we invite readers to contribute to this open project.

In summary, accurate and legible admission clerkings are essential across all specialties to allow for continuity of care and management. Our predrawn diagrams speed up the clerking process while being more legible and easier to interpret. We have designed an online ‘clerking collaborative’ where doctors can download our proforma, contribute improvements and upload their own customised forms for other specialties.


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  • Contributors AAH, RE and NM helped with the conception and design of the study, interpretation of data and drafting of the manuscript. SKL helped with study conception and critical revision of the manuscript. All the authors helped with revision of the manuscript and then gave final approval of the version to be published. AAH is responsible for the overall integrity of the content.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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