EnPHC Documentation Protocol

Diseases Covered Under EnPHC

EnPHC (Enhanced Primary Healthcare Clinic) is the overarching programme managing the three core NCDs:

DM

Diabetes Mellitus

HPT

Hypertension

DLP

Dyslipidemia

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Protocol Lifecycle

01

Register

Register new patient via Referral & Register Special Services template

02

Screen

Complete mandatory baseline screening at NCD unit

03

Activate

Set Active EnPHC status and confirm diagnosis via EnPHC Checklist

04

Complete

Fill in comorbidities, hospital history, blood results, and screening data

05

Monitor

Active follow-up throughout treatment

06

Update

Append status changes only — never delete existing codes

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Registration & Activation Workflow

1

Register New Patient

Initial registration using the Special Services template

Template Used: Referral & Register Special Services

Complete the template by ticking and filling in the relevant diagnoses:

• Diabetes Mellitus
• Hypertension
• Dyslipidemia
• Pre-Diabetes

Mandatory fields:

1. Date of diagnosis
2. Tick and complete all blood screening and procedures that have already been performed

After completing the template, you may optionally print the registration form for the NCD unit's records.

2

NCD Unit Processing

Referred to NCD unit to complete registration and mandatory screening

The patient is referred to the NCD unit to:

1. Finalise the registration process
2. Verify that all mandatory screening and investigations have been completed

If any tests or screening are outstanding, they must be arranged and completed at this stage before the patient is formally activated.

3

Activate EnPHC Status

Set the patient as Active Enhanced Clinic using the EnPHC Checklist

Template Used: EnPHC Checklist

Under the Case Status section, tick the following:

• Active EnPHC
• The patient's confirmed diagnosis — one or more of:
  • Diabetes Mellitus (with diagnosis date)
  • Hypertension (with diagnosis date)
  • Dyslipidemia (with diagnosis date)

Active Status Requirements

Every active EnPHC patient must have both:

1. Active EnPHC status
2. At least one confirmed diagnosis (DM, HPT, or Dyslipidemia) with a recorded diagnosis date

This activation step is performed only once for the entire duration of the patient's treatment at the EnPHC clinic.

4

Complete Patient Information

Ensure all key patient details are documented in SystmOne

The staff in-charge must ensure the following are fully documented:

1. Comorbidities — all known conditions with their respective diagnosis dates
2. Hospitalisation history — any previous admissions
3. Specialist appointments — any existing hospital follow-ups for other conditions
4. Blood investigation results — complete and up to date
5. Complication screening — completed according to the scheduled screening calendar

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Ongoing Status Management

Throughout the patient's treatment, they may fall into one of the following categories. Staff must update the status accordingly — always by adding a new code, never by removing existing ones.

Patient Status Reference

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

ActiveActive EnPHC

Patient is attending follow-up as scheduled with no defaulting.

DefaulterDefaulter

Patient missed their scheduled appointment. Specific definition varies by clinic locality.

Transfer-OutTransfer-Out

Patient requests to continue treatment at another health facility.

Transfer-InTransfer-In

Patient from another facility transfers into this clinic. Treated as a new active case.

DeceasedDeceased

Patient has passed away.

Non-Active Cases

Defaulter, Transfer-Out, and Deceased patients are classified as Non-Active EnPHC cases. Transfer-In patients are classified as a new Active case.

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Changing Patient Status

Active → Non-Active

1

Open EnPHC Checklist

Navigate to the EnPHC Checklist template for the patient

Open the patient's record in SystmOne and access the EnPHC Checklist template.

2

Tick New Status

Select the new status that applies to the patient

Under the Case Status section, tick the appropriate new status:

• Defaulter
• Transfer-Out
• Deceased

Do not remove the existing Active EnPHC tick.

3

Save Template

Save the checklist to apply the status change

Save the template. SystmOne will automatically update the patient's status from Active EnPHC to Non-Active EnPHC.

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Non-Active → Active (Reinstatement)

For a previously non-active patient who returns to the clinic and needs to be reinstated:

1

Identify the Non-Active Code

Locate the code that caused the Non-Active status

Go to EnPHC Checklist → Tab 1 → View Case Status section.

Identify the code that is responsible for the Non-Active status (e.g. Transfer-Out, Deceased) and note down its recorded date.

2

Navigate to Code Journal

Access the full coded entries for the patient

Go to Clinical Tree → Code Journal.

Change the dropdown filter to All Coded Entries.

3

Mark Code in Error

Remove the incorrect or outdated Non-Active code

Locate the previously noted code in the list.

Right-click on it and select Mark in Error.

This will remove the Non-Active status and restore the patient as an Active EnPHC case.

Critical Rule

No code should ever be deleted from a patient's record. When a status changes, add a new code — never remove the existing one.