Before & After CCMS

This page documents the operational changes across Klinik Kesihatan following CCMS implementation - the previous manual, paper-based system against the current digital workflow on SystmOne.

What EMR Brings to Clinical Documentation

The shift from paper-based records to SystmOne has improved how clinical units capture, store, and retrieve patient information. Key benefits include:

• Continuity of care: Any authorised staff member can review a patient's full clinical history before an encounter, without relying on physical books being present.
• Multidisciplinary visibility: Entries from doctors, nurses, pharmacists, and allied health are consolidated in one journal view, reducing information silos.
• Audit readiness: Every action is logged with a date, time, and user ID, supporting quality assurance and compliance reviews.
• Structured data capture: Standardised templates ensure consistent documentation across staff and shifts, reducing variability in record quality.
• Appointment and follow-up management: Scheduling is integrated with the clinical record, reducing missed follow-ups and duplicated appointments.

For a general overview of CCMS capabilities, see CCMS Benefits↴.

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Before vs After SystmOne

Component	Before (Manual System)	After (CCMS Implementation)
Main Record System	Large physical unit books and logbooks for each service (NCD, MCH, TB, etc.) Handwritten entries across multiple volumes.	Full digital documentation in SystmOne one record per patient.
Patient Personal Copy	Patient-held booklet or card (NCD booklet, MCH Pink Book) for meds, TCA, and key values	Patient-held booklet remains as a reference summary only meds, TCA and key values. All clinical notes and history stored digitally.
Doctor Documentation	Full handwritten documentation in large physical books and patient booklets	Real-time documentation via structured templates in SystmOne Booklet updated with latest summary only
Access to Supportive Units	Segregated documentation by pharmacist, dietitian & other units in separate books or cards	Unified journal view in SystmOne; any clinician can view the entire case flow, including support unit input
Data Accessibility	Only accessible at the clinic where the physical book is stored	Accessible from any Klinik Kesihatan using SystmOne with appropriate permissions
Lab Result Tracking	Laboratory data handwritten or transcribed into books	Automated data integration between lab-ccms (vendor basis)
Appointment Scheduling	Written in patient booklet and TCA card	Scheduled in SystmOne Rota module + TCA card issued
Medication Prescribing	Manual prescription slip handwritten by doctor	Full e-prescription via SystmOne-PhIS integration. Prescription slip printed if needed
Audit & Follow-Up Readiness	Difficult to retrieve historical data; limited audit trail	Full audit trail of documentation with date, user ID, and filterable logs for review or reporting
Backup & Disaster Recovery	Dependent on physical storage and district-specific systems (e.g., NCARDIS) If book lost, data may be unrecoverable.	Unified SystmOne cloud & data storage via MOH server infrastructure

Key Takeaway

• The shift to SystmOne has greatly improved continuity, accuracy, and efficiency of care across all units. Physical patient booklets now serve only as reference summaries containing the latest medication list, TCA date, and key values while all clinical notes and historical data are stored securely in the digital system.

• The SystmOne journal feature automatically organises entries from all staff across departments, allowing clinicians to trace a patient's full care journey (e.g., nurse assessment, specialist review, pharmacy dispensing, follow-up plan) in chronological order. This improves care coordination, clinical decision-making, and auditing.