Clinical report exam

Tomorrow is my summative exam which consists of watching a 15 min video and writing a clinical report.Eeek!

The video shows a conversation between a nurse and a patient on a certain health issue, for example, high blood pressure, cardiovascular diseases, smoking, alcohol addictions, obesity, diabetes etc.
While you are watching the video, you are allowed to make rough notes.When the video is over you are given one hour to write a clinical report based on the video. This is a PASS or FAIL exam. The report should:
– Establish the context and focus of the consultation
– Clearly identify presenting needs including any risks that have arisen
– Outline interventions provided including details of information given
– Include the patient/client perspective
– Identify any ongoing or future care arrangements
– Be clear and accurate


An example of a clinical report would look something like this:

Patient contact record                                      Baytree Medical Centre



Caroline Smith






8 Meadow Drift


Telephone number


Date of contact


6th October 2015
Time of contact


Reason for contact today (including any previous test results and observations) 




  • ·Referred to alcohol nurse by G.P. Dr. Phillips due to increasing alcohol consumption
  • ·Blood screen – normal
  • · AUDIT score 18 – ‘higher risk’
Context and focus of the consultation

Mrs. Smith attended a planned appointment at the Health Centre today to discuss concerns raised by her G.P. Dr. Phillips regarding Mrs. Smith’s increased alcohol consumption.

Presenting needs including any risks that have arisen

I informed Mrs. Smith that her recent blood results for anaemia have been returned as ‘normal’ and advised her to continue taking her prescribed medication until it has been reviewed by her GP in two weeks time.

Mrs. Smith had filled in an AUDIT form and had brought this with her to the appointment today.  I clarified my role and the focus of the appointment.  We discussed the information included in the form:  Mrs. Smith confirmed that she is drinking alcohol every day, 1 or 2 medium glasses of wine and 1 gin and tonic before bed;  Mrs Smith introduced the nightly gin and tonic 4-6 weeks ago following having problems with sleeping; this equates to 5 units a day.  Mrs. Smith told me that she drinks higher levels of alcohol at weekends, particularly when socialising, usually Saturday evenings, when she may also drink shots of spirits, and some Sunday lunchtimes.  Over the week, she is drinking an approximate average of 7-9 units per day. Mrs. Smith occasionally feels that she cannot stop drinking – about once a month at the weekend.  She has not experienced any amnesia following alcohol use.  Mrs. Smith said she never drinks in the mornings. She complained of gastric disturbances, heart burn and stomach aches, however, did not attribute them to alcohol use. Mrs. Smith shared that her husband describes her as ‘argumentative’ when drinking alcohol.  Her husband drinks ale but reasonable quantities only.  Mrs. Smith’s AUDIT score is 18, which I explained, puts her at ‘higher risk’ of developing alcohol related physical, social and psychological harms.


I explained the link between alcohol and sleep disturbance to Mrs. Smith. I also provided her with advice regarding the Government’s recommended safe limits, including having 2 alcohol free days a week, and suggested that she might find the use of a drink diary useful. I gave Mrs. Smith a unit calculator, a drink diary and an alcohol information sheet. Mrs Smith responded that she would like to change her alcohol drinking habits.

Mrs. Smith and I agreed on the following action plan:

• To reduce daily alcohol intake to within recommended limits.
• To aim for 1-2 alcohol free days
• To consider the materials given and to return for a further appointment in one week.
• To feel free to telephone for advice at any time.

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