Documentation & Medication Safety During Downtime

When CCMS (SystmOne) or PhIS is unavailable, documentation does not stop — it shifts to paper. The record-quality and accountability standards of the EMR still apply, and every manual entry must later be restored into the system. This page covers the documentation and medication-safety rules that protect patients and keep the record auditable through a downtime.

---

1. Manual documentation standards

Paper records created during downtime must meet the same characteristics an EMR record would — completeness, accuracy, timeliness, clarity, and authenticity (ISO 18308).

Manual Record Requirements

• Use the standard fallback forms (manual clerking sheet, prescription slip, consent form, unit logbook) — not loose paper.
• Record patient identifiers on every sheet (name + IC/MRN) per the two-identifier rule.
• Write the date, time, and author on each entry; sign every note.
• Keep entries contemporaneous — written at the time of care, not reconstructed later.
• Do not discard any manual record after re-entry — they are retained for audit.

Audit continuity

Manual records bridge the audit trail across the outage. Once re-entered, the CCMS audit log resumes capturing who/when/what — preserving the unbroken accountability chain expected by ISO 27789 and DKICT-V5.

---

2. Mandatory data re-entry after recovery

Re-entry is not optional. It closes the data gap that downtime creates and is required by ISO 22301 (return to normal operations) and ISO 27001 (complete, auditable records).

Collect manual records

Unit coordinators gather all paper documentation used during the outage.

Re-enter into CCMS / PhIS

Assigned staff transcribe manual entries into the system, preserving the original date/time of care in the note.

Cross-check accuracy

A second person verifies that paper records match the digital entries before the manual set is filed.

Re-entry priority

Prioritise critical patients first — emergencies, scheduled procedures, and medication refills — before routine consultations.

For the facility-level recovery workflow, see the Recovery Protocol↴.

---

3. Medication safety during downtime

Manual prescribing and dispensing carries a higher medication-error risk because the EMR's drug-interaction checks, allergy alerts, and PhIS verification are temporarily unavailable. Extra safeguards apply.

Manual Dispensing Safeguards

Legible, complete slip

Prescriptions written on the manual prescription slip with full patient identifiers, drug name, strength, dose, route, and frequency.

Independent double-check

Pharmacist verifies drug, dose, and patient before dispensing — the human substitute for the system's automated checks.

Reconciliation

All manual prescriptions are reconciled with PhIS once the system is restored. PhIS

Medication Error Reporting

MOH MERS

Any medication error — during downtime or discovered on re-entry — must be reported through the MOH Medication Error Reporting System (MERS), in line with the Pharmaceutical Services Programme (Bahagian Perkhidmatan Farmasi, KKM) requirements.

No concealment

Errors are documented and corrected transparently, never hidden — consistent with the documentation non-conformity and correction workflow.

When the error is found on re-entry

If a downtime medication error is discovered while transcribing into CCMS, correct it using the standard Mark In Error↴ workflow (with a documented reason), and submit the MERS report. This preserves both the original entry and the correction for audit.