Clinical Workflow

Registration and identification

Every encounter starts with knowing exactly who the patient is. Safety standards recommend at least two identifiers — such as full name and date of birth — before any assessment, test, or medicine. A bed or room number is never enough. ^[1]

Registration also captures allergies, current medicines, and key history, which every later step depends on.

Assessment: history, examination, investigations

The clinician takes a history (presenting complaint, its course, past history, medicines, allergies, family and social history), examines the patient, and records vital signs. Investigations such as blood tests or imaging are ordered to confirm or rule out possibilities.

The result is an assessment — a working diagnosis and a list of differential diagnoses — and a plan.

Documenting with SOAP

• S — Subjective: what the patient reports, in their words.
• O — Objective: examination findings, vital signs, and results.
• A — Assessment: the clinician's interpretation and differential diagnoses.
• P — Plan: investigations, treatment, advice, and follow-up. ^[2]

Prescribing, verification, and administration

A prescription should be clear and complete: drug, dose, route, frequency, and duration. Before dispensing, a pharmacist independently checks the dose, interactions, allergies, and contraindications.

When a medicine is given, the classic five rights apply: right patient, right drug, right dose, right route, and right time. ^[3] Many settings add right documentation and right reason.

Handover and follow-up

Care often passes between people and shifts. SBAR — Situation, Background, Assessment, Recommendation — keeps handovers short, structured, and complete. ^[4]

Finally, the plan needs a clear follow-up: when to review, which results to chase, and what the patient should watch for at home.