OPD Documentation Standards

This page consolidates CCMS / SystmOne documentation standards for the general patient journey at KK Bandar Maharani. It covers template selection, who documents what at each stage, order creation mechanics, checklist rules, and coding requirements. Disease-specific templates and unit-level documentation SOPs remain in their respective unit pages.

Checklist Update Rules

The physical patient checklist tracks the patient's location and completed steps. Update it manually at the following mandatory checkpoints:

Checkpoint	Who Updates	What to Record
Before sending to investigation / procedure	Doctor	Test name / procedure type; Order Number; Room Num.
Before sending to referral	Doctor	Referral type; destination; letter printed
After procedure completion	MA / Nurse	Procedure done; outcome; any complications
After imaging completion	Radiographer	Order completed; DICOM transferred
After result review	Doctor	Results reviewed; plan updated
Before discharge	Doctor / Counter 17A	Encounter complete; TCA issued (if applicable); pharmacy direction

Visit Checklist

Visit Checklist

---

Documentation Checkpoints by Journey Stage

1

Triage

• General patient triaging and stratification
• Flag risk indicators: fever/respiratory symptoms, pregnancy, notifiable disease suspicion, danger signs.
• Document redirection decision and destination unit.

2

Registration

• Verify and update patient personal details, demographics & contact details.
• Record entitlement, exemption status & social flags (OKU, BSH/PBAPP, pensioner).
• Confirm appointment / TCA status and allocate patient to correct unit queue.

3

Vitals & Screening

• Document vital signs: BP, PR, SpO₂, temperature, pain score.
• Document latest anthropometry: height, weight, BMI, RBS.
• Assessment & Procedure Template for documentation purposes.
• Complete relevant screening forms: BSSK, NHSI, PEKA B40, PHQ-9 where indicated.
• Record any abnormal findings and escalation actions taken.

4

Doctor Consultation

• Select the correct clinical template for the encounter type.
• Use free text consultation for any non-specific condition or complaints.
• Document history, examination findings, assessment, and working diagnosis.
• Enter SNOMED-CT / ICD-10 codes before saving Mandatory
• Create orders for investigations (blood, X-ray, ECG) or referrals (internal, specialist, ED)
• Update patient checklist before sending to linked services.

5

Linked Service Execution

• Procedure Room: Document procedure performed, indication, consent & outcome using the OPD Procedure Template or Emergency Procedure Template.
• Radiology: Doctor creates imaging order with indication and LMP; radiographer confirms and completes order after DICOM transfer.
• Wound Care: Document assessment and dressing using unit-specific wound care templates.
• Laboratory: Specimen collection is tracked in SystmOne; results link back to the originating order.
• Internal Referral: document in Register Special Service template, print registration form when needed

6

Return, Review & Closure

• Review investigation results or procedure completion notes before finalising the encounter.
• Update diagnosis, management plan, and checklist.
• Prescribe medications via CCMS–PHIS integration.
• Issue TCA (if follow-up required) and route patient to Pharmacy or Appointment Counter.
• Ensure encounter is coded and saved with complete documentation.

---

Order, Task & Referral Creation

When the doctor identifies a need during consultation, create the corresponding order or task in SystmOne before the patient leaves the room.

Need	SystmOne Action	Mandatory Fields	Checklist Update
Blood test / procedure	CREATE ORDER → select test / procedure	Indication, urgency	Update checklist with test name before sending to Room 8
X-ray	CREATE ORDER → generate X-ray Word Template	Site, clinical indication, LMP for childbearing women	Update checklist before sending to Room 7
ECG	CREATE TASK ORDER	Indication	Update checklist; allocate to Counter 17 area
Internal referral	Register Special Services → select service	Indication, referring doctor	Task notification sent to receiving unit
Specialist Clinic referral (HPSF)	Print & Refer Template	Clinical summary, indication	Print letter; 2-week validity
ED referral	ED Referral Letter	Clinical findings, procedure summary, referral reason	Auto-allocate to Emergency / Room 8

Never Send Without Documentation

Do not direct a patient to Room 8, Room 7, or another unit without an actionable order or task created in SystmOne. Verbal instruction alone is insufficient for audit traceability and workload tracking.