Diabetes Mellitus Documentation Protocol

Protocol Lifecycle

01

Confirm Diagnosis

Diagnosis based on blood & supportive investigation

02

Register

To complete registration via Register DM template

03

Stratify

DM team screening and processing

04

Code

Apply correct pathway

05

Monitor

Active follow-up

06

Update

Append status changes only

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Confirming Diagnosis & Registration Workflow

1

Confirm Diagnosis

Verify CPG criteria before registration

Do not register a patient unless diagnosis is confirmed by Diabetes CPG criteria and supported by documented blood investigations.

2

Register Patient

Complete template and stratification

Template Used: Register DM Template

Complete all required data:

1. Diagnosis date
2. Supporting blood investigation results
3. Case type:
   • New case
   • Transfer-in from another facility
   • Old case never previously registered

Register DM Case

Template Register DM Case

Send Task to Respected Team

After submission, SystmOne can sends a task to DM team to notify them regarding new case registration

Doctor's Role

The attending doctor responsibility is to confirm diagnosis, ensure all new registation test has been ordered and complete & task been sent to respective NCD Team for further case stratification.

Post-Registration: Case Status Update

Use the pathway below that matches your case type.

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DM Overview Template

Guide for DM Overview Template

DM Case Status

DM Checklist Template

A

Pathway A: New Case

True new DM patient, fully worked up

Criteria:

• Truly new DM patient
• Not transfer-in
• Not old unregistered case
• Investigations and diabetic screening completed

Apply codes:

• Referral to Diabetic Register
• Diabetic Control Clinic

Why:

• Referral to Diabetic Register marks registry entry (cohort/reporting)
• Diabetic Control Clinic is permanent baseline active code

Then complete DM Overview:

1. Add Nombor Daftar (MRN)
   • Path: DM Overview → Tambah No. Daftar → Add New MRN
   • Format: DM xxxx/2016
2. Register into NDR
   • Path: DM Overview → Tambah Nombor Daftar → Enter NDR Number

B

Pathway B: Transfer-In Case

Existing DM patient moving from another facility

Criteria:

• Existing DM patient from another clinic/facility
• Not a new diagnosis

Apply codes:

• Diabetic Control Clinic
• Patient moved in area

Do not apply:

• Referral to Diabetic Register — this is reserved for new cases only

C

Pathway C: Old Unregistered Case

Patient with known DM who was never formally registered before

Criteria:

• Patient has known diabetes from prior records
• Never previously registered in any facility's NCD system
• Not a new diagnosis and not a transfer-in

Apply codes:

• Diabetic Control Clinic

Do not apply:

• Referral to Diabetic Register — this patient is not a new reporting cohort
• Patient moved in area — this is not a transfer-in

Note: Because this patient was never registered, there is no prior facility to transfer from. Treat as a baseline active case under Diabetic Control Clinic and complete the DM Overview template for longitudinal tracking.

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Ongoing Case Monitoring: Case Status Update

When status changes over time after registration, add one new code. Keep existing codes unchanged.

Status Change Reference

Add one new code per event. Keep all existing codes.

DefaulterDefaulter

Add → Did not attend diabetic clinic

Transfer OutTransfer-Out

Add → Patient has moved away

Out of ZoneLuar Kawasan

Add → Miscellaneous location

DeceasedDied

Add → Patient died

Critical Rule

Always keep the permanent baseline code Diabetic Control Clinic. When patient status changes, add a new code.