bleep.guide · FY1: The Missing Manual
Monday, 27 July 2026
How to see new patients yourself, make a safe initial plan, and present for senior review.
FY1: The Missing Manual · Session 3 of 4 Monday 27 July 2026 · led by Dr Oliver Devine
Same standing line as the previous two sessions, with one addition for this one. You are never the only person responsible for the patient in front of you — and when you clerk, you are doing the first pass, not the only pass.
Every patient you clerk gets seen again by a registrar within a few hours, and usually by a consultant the following morning at the latest. Your plan is not the definitive plan, and it shouldn't be. That is what makes clerking enjoyable for more junior residents. It is also what makes it the best training you will get, because it is one of the few times in your career when you can commit to a view knowing someone more experienced will look at it almost immediately.
The uncomfortable part is that writing an impression exposes your thinking to someone with years more experience than you. But that is all it is — experience, not intelligence. I have five years more than you do; in five years you'll be doing what I do. And if anyone makes you feel bad for not knowing something, that is on them, never on you. You have already proved you are trainable by getting through medical school, and being trainable is most of what matters at this stage.
And as with every week of our series so far: none of this is your trust's policy. Where they differ, your trust wins — that goes double for the prescribing, discharge and escalation sections below.
Clerking is the first assessment and documentation of a patient who is new to the hospital. So where will you actually be doing it? A few places, and it's worth knowing which of them you'll realistically be in:
The barrier is not working out what's wrong. You'll be quite good at that. What's hard is knowing what to do about it. FY1s, FY2s and IMTs who've just seen someone on the take have usually identified the problem correctly. What they haven't got is a sensible, comprehensive plan. There are a lot of components to a plan and you have to know what they are. That gap is why this session exists, and honestly why we made the bleep.guide app.
Most of you will be on an electronic record, and the quality varies enormously — but Epic, Cerner and most of the rest let you build a smart phrase: type a full stop and a couple of letters, hit enter, and a block of text you prepared earlier drops in. Set one up before you need it.
There's nothing clever in it — it's the structure you've written a hundred times as a student: presenting complaint, past medical history, drugs, allergies, social history, what's already been done before the patient reached you, examination, impression, plan. The value isn't the content. It's that at the end of a long take you aren't rebuilding the shape of a clerking from memory. Much of this standard clerking format is what you've been doing at medical school on the wards for years.
Start with the ambulance notes. Why is this person actually here? The ambulance notes are the single best source of truth on that — the crew went to the house, saw them at home, and wrote it up in detail. Read that first.
Then prep the note before you go in. By the time you pull the curtain you should know why they came and what everyone else thinks is wrong. You'll still take your own history, SOCRATES and all, but with a shape in your head rather than from cold.
Go to the GP record for past medical history, drugs and allergies. It's the closest thing to a single source of truth for thirty years of this person's life, and the problem list should be reachable through your record. For drugs it's better than that — it shows what they're actually collecting from the pharmacy. Check the ED notes for investigations, but once a patient has been referred to medicine there's often little else in them.
Social history is the box people skip or do badly, and it's the one that decides the admission. Smoking, alcohol, drugs, who they live with, what help they have — yes. But the most important question isn't one you ask them, it's one you ask yourself: what is this patient's mobility? You can give antibiotics for a pneumonia anywhere. What determines admission is almost always whether someone has gone from walking around to not.
On examination, you don't need an OSCE-level exam on every patient. For most people it comes down to:
Do that honestly and you've performed a competent, safe examination — it's the all-purpose exam behind most clerkings and most ward rounds. Then go deep where the problem is. A neurological presentation gets a full neuro exam. A pyrexia of unknown origin where endocarditis is on your mind gets the heart sounds listened to in detail and a careful hunt for peripheral stigmata.
Most hospitals, including ones that otherwise work on paper, have an electronic trackboard — the live list of who's been referred to your specialty and where they are. On your first shift someone will ask if you've done this before, you'll say no, and they'll show you how it works. What you want off it is who's still to be seen and how long they've waited.
So who do you take first? You can ask your registrar, or work in time order, and as you get more experienced you'll start prioritising by NEWS. But here's the advice that surprises people.
Pick the patients who sound sicker. Someone in majors or already in a bed might sound more serious than someone in the waiting room, but this is someone ED and/or the medical registrar have effectively decided is being admitted, even if that hasn't been formalised yet. They tend to be older and frailer, their conditions are known about, and what's happening is usually an exacerbation of something familiar — the patient with COPD and their third pneumonia this year, who gets around the house at baseline but goes off legs every time. Far more legible than a 31-year-old in the waiting room with some breathlessness and a mild tachycardia, who might have a PE, might not, might need scanning today, might go home.
*In my experience, it's the admit or discharge question that makes a patient junior or senior work*, not how unwell they look. If the answer is almost certainly "coming in", that's a good patient for you.
What actually turns up? Going by which clerking plans you all opened in the app last week — so treat this as a rough shape, not data. Chest pain and suspected ACS is far and away the biggest thing on a medical take, and the one that worries people most. Then, roughly: falls, heart failure, sepsis. AKI, gastroenteritis, stroke, palpitations and hypertensive emergencies all feature. That's most of a take — a fairly short list covering 80–90% of what comes through the door, and for everything else you have someone more senior or a more challenging case to take on yourself.
There are two ways this goes. Either you're sent to see someone alone and come back with an impression and a plan — uncomfortable at first, and the version you learn from — or you go with a senior and become a glorified scribe, which feels like a ward round rather than a take. Scribing is genuinely useful early on, while you learn the systems, and it's up to you which you're comfortable with. But over time you'll get far more from seeing patients yourself.
And you do add something. You're slower, but you're usually more thorough, and you don't yet carry the pattern-recognition bias that makes me walk in already believing this is a PE. You'll spend an hour with someone and elicit what I didn't, because I spent much less time with them. That's the point of a junior-and-senior take. But you have to be good at this before you can be fast at it, so don't let anyone push you to see patients quicker than you can see them properly.
On numbers: people say one an hour, and one an hour is about what I manage. Think what it contains: prep, a room, a computer, history, examination, plan, referrals, investigations, a call to radiology, maybe a hot clinic or SDEC follow-up. Plenty of consultants would disagree and say it should take less than an hour. But if I saw an FY1 clerking one patient every two hours, I'd still think that was pretty good. Seven across a twelve-hour shift is exceptional. And ignore anyone suggesting twelve in twelve: an hour of a rostered twelve-hour day shift is paid break — an hour and a half if it's a night — with half an hour at each end for handover.1
Meds reconciliation, the VTE assessment and the escalation form. Skip them and people will find you quickly. They're time-consuming, unglamorous, and they fall to the most junior member of the team. I hated them, and still don't enjoy them. They're also where an FY1 can do real harm, so do them properly rather than fast.
This is where your errors are least likely to be caught. The patient you're writing up may not see a consultant until tomorrow morning, a full day away. Pharmacists don't live in ED or on the take — they're on the wards patients go to next — so there may be no pharmacy check either. So who catches it? It isn't that you'll make more errors here than anywhere else — it's that here they sit uncorrected, and what you write is what the nurses will give.
The method: go to the GP record and look at the last issued date. That date tells you the drug is genuinely being dispensed to this patient, which is a much better signal than its presence on a list. Write down the recently issued ones, take that list to the bedside, and ask: can I go through these and you tell me which you're still taking?
Some patients can't do that, and then you want the relative — in the department if they're still there, on the phone if not. It takes time you'll feel you don't have. The test is the one you'd apply to your own family: you'd expect someone to check what the patient is actually taking. It doesn't always happen.
At medical school this is an OSCE station and feels theoretical. In practice the e-prescribing system flags that the patient needs assessing, walks you through a checklist of risk factors, and offers you a box to prescribe in — a standard prophylactic dose for an average-weight adult, which you adjust for weight and renal function. The checklist scores clot risk against bleeding risk, and the bleeding half is the one worth reading rather than clicking through.2
If you're on a paper system, be more careful. I think it's now under one in ten hospitals, but they exist, and none of that prompting happens for you.
Most trusts expect CPR status to be considered and recorded for every acute admission, often within the first twenty-four hours — check your own trust's policy.3 Considered isn't a form on everyone, and certainly isn't a conversation with everyone: if arrest isn't reasonably foreseeable this admission, you don't need to raise it.4 Clerking is where the job lands. Form the judgement early — just don't have the conversation in a rush you can't do properly.
Start by asking whether this conversation has already been had. Look for any previous form, however old — ReSPECT recommendations don't expire. With the older, frailer patients already in beds there's usually one. Then your job is a review, not a first conversation, and the admission is itself the trigger for it: I can see a conversation about this was recorded in March — can I check what you remember of it, and whether anything's changed since?
If there's no previous form, talk to your registrar before you go in — and say plainly if you've never done one. Can you do this one, or come in with me? is the right answer in your first weeks.
Work out which of two situations you're in — the rules differ. The first is CPR that wouldn't restart the heart and breathing for any sustained period, in someone dying of advanced, irreversible disease: it isn't a treatment on offer, so it's not a menu option and nobody can demand it. The second is CPR that might work but where the burdens may outweigh the benefit. That one is expressly not solely a clinical decision — it's shared, and where it's finely balanced the patient's view usually settles it. You'll meet it often.
In the first situation, don't ask the patient what they think we should do — that offers a menu that doesn't exist. But do have the conversation. The presumption is in favour of involving them and it takes convincing reasons not to; distress alone isn't enough, the bar is harm.5 With capacity, get their agreement before you talk to the family. Without it, you must consult those close to them before the decision goes on the record — inconvenient isn't the same as impracticable.6 Offer a second opinion if it isn't accepted.
Know the real numbers before you talk about them. Across UK in-hospital arrests about a quarter of patients survive to discharge — but that average hides everything that matters: a little over half where the first rhythm is shockable, roughly one in six for PEA, one in nine for asystole.7 For the patient in front of you with several organs failing it is lower again, and that is the honest basis for what you say. What we don't have is good national data on how survivors do neurologically, so don't claim to know.
Roughly how I frame it: it's very unusual for something really bad to happen in hospital, but occasionally it does and we like to be prepared. If your heart were to stop, I don't think shocks and pressing on your chest would get it going again — and there's a real risk of brain injury in those who do come back. It's not what you see on Casualty or Holby City. Your heart, kidneys and chest have got to the point where if they were sick enough to stop your heart, I don't think we'd get it beating again for long. None of this changes anything else — the antibiotics, the fluids, the oxygen all carry on exactly the same.
Say that last line — it's what people are actually frightened of.
Most people I've had this with took it better than I expected, and several said they'd been worrying about it too. It isn't a signed-off FY1 competency — the curriculum puts initiating DNAR discussions in the FY2 column — but recognising the dying patient is squarely FY1, so ask to sit in early. Always agree the call with your senior. You sign the form; the senior responsible clinician endorses it, usually a consultant. Write it up in the notes as well as on the form: who you spoke to, what you said, what they understood. You'll get more confident having the conversation; the decision stays with your senior.
The impression is the part you're going to struggle with — that's from watching a lot of people struggle with it. Everything before it is information-gathering, which you're already excellent at. This is where you connect it up.
My trick is to write the impression first. Come out of the room, sit down, and write the impression before the history or the examination. So much of what you think is in your head at that moment, and spending fifteen minutes typing up the presenting complaint first will distort it. It also means you don't lose it, which is a real risk on a busy take.
So what does a good one look like? Longer than feels natural. Here's one of mine, taken apart:
Note what that isn't. Not a list of differentials — a logical account of what you found, then what you think it is, then what has to be excluded before that's safe. It could be any or all of them at once, which is exactly why an impression should never be a single word. "Impression: ?MI" can't be right after a first clerking; it's essentially impossible for a patient to be only one thing.
Having sat through a lot of clerkings, here's what works.
Don't read your clerking out. Definitely don't start at the presenting complaint and work through to the systems review — you'll tie yourself in knots, and very few people are still listening by then. Try not to read off the screen at all, which I know is easier said than done.
So what does your registrar need first? What you think is wrong and why, and whether they're coming in or going home. "I think this is musculoskeletal chest pain, but there are a few things to rule out before it's safe for them to go home." Now the registrar can ask what you want to rule out, you'll say PE and ACS, and the next question is what you've ordered. That's a conversation, rather than you reciting a clerking.
Say the disposition early, because it changes what happens next. "Their sodium is low and they can't keep fluids down, they need admitting" tells the registrar straight away whether they need to walk down there. Or, longer: "I think this is venous insufficiency, but one leg is painful so I want to rule out a DVT; both legs are swollen so we should probably rule out heart failure; they're otherwise well and walking, so I think they can go home." Now the plan almost writes itself — a BNP ± furosemide (which could be given orally and come back to SDEC) and an outpatient echo, neither of which needs an inpatient bed, a DOAC while we wait, and an ultrasound in a couple of days.
Speculate on the diagnosis. Ask everything else, write everything else, but commit to a view — it's the thing that still separates us from the clerking AI, which is getting good but isn't there. Then document the outcome: discussed with the registrar, plan as above with the following additions.
Discharging someone needs more senior input than admitting them. Policies differ. Some trusts require a face-to-face review before any patient goes home — meaning an FY1 cannot discharge alone — and mine requires it for anyone below a post-PACES SHO.
*The plan to avoid is: admit under medicine, await bloods, senior review. It happens a lot. It feels safe under time pressure, and there's little medicolegal exposure to you in admitting somebody — though there is risk to the patient in an admission they didn't need. They were getting a senior review anyway; what's being spent is your training, and in a couple of years you'll be doing those reviews. Nobody expects your plan to be right. They expect it to be sensible, and above all they expect it to exist.*
Is there a shape to the day, like there was for a night shift? Not really — it's rinse and repeat.
You arrive at eight somewhere like AMU. The night team are there in body only. The consultant comes in half an hour later, does a roll call, hears what was serious overnight, and sends the night team home. A couple of minutes later you're into it.
Ask your registrar who to see first. Find a computer, pull up your template, prep from the ambulance and GP notes, go and see them. Ideally it's all documented within about forty minutes. Then find the medical registrar or the acute physician running the take, discuss it, and move on.
Don't wait for one patient to finish before starting the next. Waiting for resolution could mean waiting six hours for bloods. See them, make the plan, order the tests, write down what's outstanding, and clerk the next one. You'll accumulate a backlog trailing behind you — a D-dimer landing, a CT you're still waiting on. That's normal, and managing it is most of the skill of a take shift.
What are the biggest mistakes FY1s make while clerking? The plan that says admit and await senior review. The history, examination and social will all be there and they'll be good — you're excellent at gathering information from day one. What takes time is connecting what you know to the pattern that says musculoskeletal chest pain, not a heart attack. After that it's the paperwork: is the meds reconciliation done, is the VTE prophylaxis prescribed. That's what people, especially consultants, gripe about.
Anything specific to surgical clerking? Two things make you unpopular fast: not ordering a coagulation screen and a group and save for someone coming in overnight ahead of theatre — and not handing over that you've sent them. If the sample never reaches the lab, your shift ends and the nurses don't spot it, that's the Swiss cheese lining up, and you'll feel the heat at eight.
And on the medical side, chase your scans. Call the radiology registrar to get it protocolled and approved, then the coordinator for a time, then write that time in the notes. Otherwise the consultant arrives to a scan that's been ordered but never protocolled and never booked, and the patient has lost a day.
If there's a delay before senior review, how much of my plan should I action myself? Bloods are benign — action them. Imaging depends on the imaging. But the premise is a bit off. A senior review can be as small as you sitting down next to the registrar running the take and saying I've seen this patient, here's my plan. The answer might be that the CTPA doesn't need doing today — start a DOAC, bring them back for it.
Say you think it's cauda equina and want an MRI, though, and that registrar is coming to see the patient face to face — and if they don't agree, they may cancel it. There shouldn't really be a delay: you flag the patient as awaiting senior review, there are never more than a handful on the list, and we'll get to you within the hour. Smaller DGHs tend to be quicker still.
How do I know when to move on to the next patient? Provided they're stable, don't wait for anything to resolve. See one, make the plan, order the tests, note what's outstanding, clerk the next.
Do I do meds reconciliation and VTE for everyone in ED, even in the waiting room? No. If you're the ED FY1, you wouldn't normally do them — that's the receiving team's job, and ED's job is mostly to get people home. On the receiving team, if the patient is likely being admitted, then yes, every one. Another reason to start with the patients already in beds: those are almost certainly coming in.
Clerking alone — can you retain it all, or write as you go? I struggle with this too. It does get better, and eventually you can walk in with nothing. Starting out, take a computer in, or a clipboard and paper — don't try to hold a whole clerking in your head. Part of why I write the impression the moment I leave the bay is that otherwise I'd lose it.
Any tips for handing over after clerking? The way you presented as a student, having seen a patient with your clinical partner, is precisely how not to do it in real life. Cut to the chase: what you think it is, what you need to rule out, whether they're being admitted. Get those three into the first sentence and you'll be asked for the rest.
How do I prepare for clerking on wards I've had no exposure to, especially overnight? You shouldn't really be clerking for other specialties overnight — it's rare. It happened occasionally in geriatrics: a stroke patient came straight up from ED, already seen by the stroke registrar, and I clerked them because the registrar was busy. If you're asked to clerk while holding the ward-cover bleep — which would be challenging, because ward cover is busy — ask the registrar exactly what's required of you.
Any tips for trauma and orthopaedics? Much the same as vascular: patients coming in for tomorrow's list, or patients the registrar has effectively already assessed who need the paperwork doing properly.
Does the same format go for paediatrics? Probably — but I've never done a paediatric job, so take that with a pinch of salt. Be guided by your team there.
Ward rounds, and note-taking? Both covered in detail in the shadowing-week notes, linked at the foot of this page.
What does ward cover actually consist of? Sessions one and two. In short: you carry a bleep for a set of wards, and every out-of-hours question the nurses have about those patients comes to you.
How do I handle being asked to prescribe for non-prescribing practitioners? They should have a supervisor, usually a consultant. The wording that works: I'm not able to do that — it isn't within my scope of practice and I don't feel competent to. Could you ask your supervisor? It puts you in an awkward social position, but it's the safest thing for you and for the patient. If you do prescribe on someone else's proposal, you have to be satisfied it's needed, appropriate for that patient and within the limits of your competence — and you are responsible for the steps you take.8
I've had this from paracetamol and ibuprofen requests in ED by physician associates, up to being handed a stack of ten exchange blood transfusion prescriptions as an FY1 — eight units of blood per patient — and asked to sign them. The answer was no: I don't know these patients, I'm not a haematologist, and I'm not competent to prescribe that. Say it out loud, and take it to your educational supervisor. Usually it's agreed that it isn't appropriate.
What does the bleep.guide app cost after the trial? Everyone attending this session has ninety days. Beyond that we haven't finally decided — whether we can keep it free and ad-supported is an open question. It's currently listed at £1.99 a month, which is roughly what the servers and hosting cost.
Wednesday 19 August, 19:00 — Two Weeks In: your questions, answered. Two weeks into the job, with a panel of resident doctors — last year's FY1s, a couple of SHOs, a couple of registrars — answering what you've actually hit. I'll email beforehand asking what you want covered, and how many come in will decide whether we run it that way, so do send them.
After that we're planning FY1: Back to Basics — around eight half-hour sessions on the practical things: fluid prescribing, pain management, the rest of the on-call jobs. Notes up as always.