NCD Documentation Standards

Scope Boundary

This page covers NCD-specific documentation — DM/HTN condition tables, complication screening records, and the physical NCD booklet workflow. For general CCMS documentation standards (template selection guide, documentation checkpoints, coding rules, checklist updates, and common errors), see OPD Documentation Standards↴.

1. What Must Be Documented

Every NCD encounter must be documented completely and accurately in SystmOne using structured templates. The following items are mandatory for all NCD cases.

1.1 Diabetes Mellitus

Documentation Item	Requirement
Diagnosis & Type	Type 1 or Type 2; date of original diagnosis
Control Status	Latest HbA1c value and date; target vs actual
Complication Screening	Fundus exam date & result; foot care assessment date & risk grade; nephropathy status
Current Medications	All DM meds with dose, frequency, and any recent adjustments
Lifestyle Counseling	Diet, exercise, smoking status documented
Comorbidities	HTN, dyslipidemia, CKD, CVD and their management status
Referrals	DM-MTAC, dietitian, physiotherapy — with indication and outcome
Follow-up Plan	Next TCA date, interval, and investigations due

1.2 Hypertension

Documentation Item	Requirement
Diagnosis & Date	Date hypertension first diagnosed
BP Trends	Latest readings with dates; home BP readings if available
Risk Stratification	CV risk category based on BP level + comorbidities
Current Medications	All antihypertensives with dose, frequency, tolerability
Lifestyle Counseling	Salt reduction, weight management, exercise, smoking
Complications & Comorbidities	LVH, CKD, retinopathy, DM, CVD status
Investigations	RP, LFT, FSL, UA, ECG — dates and key results
Follow-up Plan	Next review date and BP target

SNOMED-CT Coding

Accurate SNOMED-CT↴ diagnosis coding is mandatory before saving every encounter. This ensures standardized data for reporting, audit, and inter-clinic transfer.

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2. General Documentation Requirements

In addition to the NCD-specific fields above, every NCD encounter must include the standard documentation items below. These are clinic-wide requirements shared with all units:

• Complete presenting complaint and chronic disease history, including control status and complications
• Investigations requested via SystmOne with results linked back to the encounter (HbA1c, lipid panel, renal function, urinalysis)
• Management plan including medications prescribed via CCMS–PHIS integration↴, lifestyle advice, and follow-up interval
• Referral documentation using relevant SystmOne referral templates with clear indication
• Use of the Reminder system in SystmOne to notify the primary doctor of referral outcomes or actions required

For coding requirements (SNOMED-CT, ICD-10), checklist update rules, documentation ownership matrix, and common errors, see OPD Documentation Standards↴.

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3. Physical NCD Book Workflow

The small green NCD booklet remains a patient reference tool and a medico-legal backup for continuity of care.

Doctor Consultation Complete

Doctor complete the consultation records in CCMS, and making sure all other relevant information documented in CCMS.

Update Patient Booklet

Record the following in the booklet:

• Vital signs & anthropometry details
• Latest HbA1c and key laboratory results (if available)
• Current medication list
• Next TCA date

Verify & Return to Patient

Hand the updated booklet back to the patient. Remind them to bring it for every NCD visit. If the patient forgot the booklet:

• Document in SystmOne that the booklet was not brought
• Remind the patient to bring it for every NCD visit
• Issue any urgent results or medication changes on a temporary slip if clinically necessary

NCD Large Folder

The clinic-held large NCD folder contains historical records that predate full CCMS digitalization. It does not need to be retrieved for patients whose records are fully digitalized unless specifically requested for audit or legal purposes.