NCD Staff & Roles

1. Objective

The Non-Communicable Disease (NCD) Unit delivers structured, long-term management for chronic conditions through a multidisciplinary team. Care emphasizes timely screening, appropriate consultation allocation, accurate documentation, and coordinated follow-up to improve clinical outcomes and audit readiness.

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2. Organisation

Leader NCD Unit

Dr Rosnah Tahir

FMS

Outpatient

Doctor16 yrs

Dr Amalina

PIC, NCD

Non-Communicable Disease Unit

Doctor13 yrs

MA Izzati Yunus

Coordinator, NCD

Non-Communicable Disease Unit

MA12 yrs

Team Members

Dr Nurul Liyana Mohd Nor

Coordinator, NCD

Outpatient

Doctor12 yrs

MA Farahain

Coordinator, NCD

Outpatient

MA8 yrs

SN Siti Barkes

Coordinator, NCD

Infectious Disease Control

Nurse20 yrs

SN Farizatul Norazreen

Coordinator

Non-Communicable Disease Unit

Nurse16 yrs

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3. Staff & Roles

Staff Count	Role	Location	Responsibilities
👤👤+5	Medical Officers (MO)	NCD Doctor Rooms	Daily patient management, scheduled and walk-in NCD follow-ups, medication adjustment
👤👤	Family Medicine Specialists (FMS)	NCD Doctor Rooms / Room 21	Oversight of complex cases, supervisory governance, audit leadership, NCD case discussions
👤👤👤	Medical Assistants & Staff Nurses	NCD Screening Area	Perform all NCD screening, patient education, complication surveillance, defaulter tracing, and data entry as a unified team
👤	Diabetic Educator (DE)	NCD Screening Area	Diabetes counselling, complication screening coordination, patient education
👤	Pharmacist	Pharmacy / DM-MTAC	DM-MTAC reviews, pharmacological monitoring, polypharmacy review
👤	Dietitian / Nutritionist	Dietitian Room	Meal planning, obesity management, diet-related glycemic control
👤	Physiotherapist	Physiotherapy Room	Physical activity prescription, rehabilitation for neuropathy and limited mobility

For the full clinic staff directory with master overview table, see KKBM Organisation Structure↴.

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4. Scope of Work (Clinical Team)

Medical Assistants and Staff Nurses work as a single integrated team. The following sections cover the full scope performed by the NCD clinical team.

Screening & Risk Stratification

Vital Signs & Anthropometry

• BP, heart rate, weight, height, BMI, waist circumference
• CVD risk scoring using WHO/ISH risk prediction charts

Blood Glucose & HbA1c

• Fasting blood sugar (FBS) and random blood sugar (RBS)
• HbA1c POCT and venous HbA1c collection
• Urine dipstick — glucose, ketones, protein, microalbuminuria

Diabetic Foot Screening

• Monofilament 10 g test for loss of protective sensation
• Tuning fork (128 Hz) vibration sense assessment
• Doppler for pedal pulse assessment and ABI calculation
• Foot inspection — deformity, callus, ulcer, infection

Retinal Screening

• Fundus photography for diabetic retinopathy screening
• Image grading and referral trigger for sight-threatening retinopathy

Baseline Investigations

• 12-lead ECG for baseline cardiac assessment - procedure done by PPK
• Lipid profile, renal profile, urine ACR/PCR - procedure done by Room 8 staff
• Influenza and pneumococcal vaccination status check

Chronic Disease Follow-Up

Diabetes Mellitus (DM)

• Scheduled and walk-in DM follow-up: review SMBG log, HbA1c trend, medication adherence
• Insulin initiation and titration support under MO/FMS guidance
• Hypoglycemia and hyperglycemia emergency management
• DM-MTAC referral coordination

Hypertension & Dyslipidemia

• BP monitoring, medication adjustment under protocol
• Lipid panel review and statin adherence counselling
• Lifestyle modification reinforcement — diet, exercise, salt reduction

Asthma / COPD

• Symptom review, peak flow monitoring, inhaler technique check
• Step-up / step-down therapy under MO direction
• Vaccination (flu, pneumococcal) for chronic respiratory patients

CKD & Obesity

• CKD staging and MOPC referral preparation
• Weight management — BMI tracking, dietitian referral

Complication Surveillance

Annual Review Bundle

• Annual diabetic foot exam (monofilament + Doppler + ABI)
• Annual retinal screening via fundus photography
• Annual renal function — urine ACR, serum creatinine, eGFR
• Annual lipid profile and CVD risk reassessment
• Neuropathy assessment — monofilament, tuning fork, ankle reflex

Referral Triggers

• Sight-threatening retinopathy → ophthalmology referral
• Foot ulcer / Charcot foot → wound care clinic / vascular referral
• CKD stage IIIB and above → MOPC referral
• Poor glycemic control (HbA1c > 10 %) → FMS review + DM-MTAC
• Resistant hypertension → FMS review

Patient Education & Counseling

Self-Management Education

• Diabetic self-management — SMBG technique, insulin injection, hypoglycemia recognition
• Home BP monitoring and diary-keeping
• Foot care education — daily inspection, appropriate footwear, when to seek help
• Medication adherence counselling and side-effect awareness

Lifestyle Counseling

• Dietary counseling (with dietitian) — carbohydrate counting, portion control
• Physical activity prescription (with physiotherapist)
• Smoking cessation advice and quit-smoking programme referral
• Weight management goal-setting

Defaulter Tracing

Defaulter Management

• Monthly defaulter list generation and reconciliation
• Phone call / SMS / home visit tracing for missed appointments
• Document all contact attempts in patient record
• Reschedule defaulters and update TCA date

Documentation & Registry

NCD Registry & KPI Tracking

• NCD registry data entry in CCMS — complete and up-to-date for every patient
• KPI tracking: HbA1c < 7 %, BP < 140/90, LDL targets, retinal screening rate, foot exam rate
• Clinical audit data collection for monthly and quarterly reporting

Folder & Booklet Maintenance

• Large NCD folder — clinic-held physical record for historical data
• Small Green NCD booklet — patient-held reference: latest HbA1c, medication list, TCA date
• Ensure both are updated at every visit

Referral Documentation

• Prepare referral letters for FMS review, specialist clinics, MOPC, DM-MTAC
• Document referral outcomes and recommendations in patient record

Quality & Administration

Reporting

• Monthly NCD unit report — patient load, screening coverage, KPI dashboard
• Quarterly audit preparation and presentation

Equipment & Stock

• Daily equipment checks — fundus camera, glucometer calibration, Doppler
• Glucose strip, urine dipstick, monofilament, and consumables inventory
• Temperature log for glucometer strips and medication storage

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5. Equipment & Screening Tools

Clinical Equipment

Fundus Camera

Retinal imaging for diabetic retinopathy screening and risk stratification

Foot Care Screening Kits

Monofilament, tuning fork, and Doppler for diabetic foot risk assessment

Vital Signs Devices

Digital BP monitors, glucometers, weighing scales, and height rods

ECG Machine

12-lead ECG for baseline and annual cardiac assessment

Documentation Materials

Large NCD Folder

Clinic-held physical record for historical data that predates full digitalization

Small Green NCD Booklet

Patient-held reference containing latest HbA1c, medication list, and TCA date

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