EnPHC Documentation Protocol

The Enhanced Primary Healthcare Clinic (EnPHC) programme is a structured care framework for managing non-communicable diseases at the primary care level. It covers three core NCDs — Diabetes Mellitus Hypertension Dyslipidemia — and standardises patient screening, case registration, ongoing status tracking, and clinical documentation within SystmOne.

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Screening

Under the Enhanced Primary Health Care (EnPHC) initiative, NCD screening operates at two levels — facility-based (secondary triage) and community-based outreach. All patients must complete screening before proceeding to case registration and activation.

1. Eligibility

Screening is structured by age and setting:

Level	Target Age	Scope
Facility (Secondary Triage)	≥ 30 years	All adults attending the clinic
Community Outreach	≥ 18 years	Adults living within the clinic's catchment area

The National Health Screening Initiative (NHSI) initially covered those ≥ 30 years in 2022 and expanded to ≥ 18 years in 2023.

2. Community-Level Screening

Community outreach involves population enrolment, NCD risk profiling, and screening conducted by mobile health teams and volunteers during medical camps. A population database with NCD risk profiles is maintained for the clinic's catchment area.

3. How Screening Is Done

In SystmOne, screening is conducted using the NHSI Screening Template via the Register & Refer Special Hub.

1

Open Register & Refer Special Hub

Access the Special Hub from the patient record

From the patient's SystmOne record, navigate to the Register & Refer Special Hub.

2

Complete NHSI Screening Template

Document all baseline screening parameters

Fill in the NHSI Screening Template with:

• Vital signs (blood pressure, heart rate, BMI)
• Anthropometric measurements
• Risk factor assessment
• Family history documentation
• Relevant investigation results

Mandatory Screening

All fields in the NHSI template must be completed before the case is handed over to the NCD unit. Incomplete screening will block registration.

3

Refer to NCD Unit

Hand over the screened patient for registration

Once screening is complete, refer the patient to the NCD unit for case registration and activation.