Hypertension Documentation Protocol

Protocol Lifecycle

01

Confirm Diagnosis

CPG diagnosis with ≥2 BP readings

02

Register

Complete registration via Register Hypertension template

03

Stratify

Baseline investigations and screening

04

Code

Apply correct pathway

05

Monitor

Active follow-up

06

Update

Append status changes only

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Confirming Diagnosis & Registration Workflow

1

Confirm Diagnosis

Verify CPG criteria before registration

Do not register a patient unless diagnosis is clinically confirmed and supported by documented blood pressure readings from at least two separate sessions.

2

Register Patient

Complete template and stratification

Template Used: Register Hypertension

Complete all required fields:

1. Diagnosis date
2. Blood pressure evidence supporting diagnosis
3. Case type:
   • New case
   • Transfer-in from another facility
   • Old case never previously registered

Register HTN Case

Tempalte Register HTN

Send Task to Respected Team

After submission, SystmOne can sends a task to HTN team to notify them regarding new case registration

Doctor's Role

The attending doctor responsibility is to confirm diagnosis, ensure all new registation test has been ordered and complete & task been sent to respective NCD Team for further case stratification.

Post-Registration: Case Status Update

Use the pathway below that matches your case type.

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HTN Overview Template

Guide for HTN Overview Template

Template HTN Overview

A

Pathway A: New Case

Truly newly diagnosed HTN patient with complete initial workup

Criteria:

• Truly new HTN patient
• Not transfer-in
• Not old unregistered case
• Required screening and investigations completed

Apply codes:

• Referral to Hypertension Register
• Hypertension Control Clinic

Why:

• Referral to Hypertension Register marks formal registry entry and new-case reporting cohort
• Hypertension Control Clinic is the permanent baseline active code

Then complete HTN Overview:

1. Add Nombor Daftar (MRN)
   • Path: HTN Overview → Tambah No. Daftar → Add New MRN
   • Format: HPT xxxx/2016
2. Complete remaining fields as needed
   • Comorbidities
   • Complications
   • Screening outcomes
   • Current medication profile

B

Pathway B: Transfer-In Case

Existing HTN patient moving into your clinic from another facility

Criteria:

• Existing HTN patient from another clinic or facility
• Not a new diagnosis

Apply codes:

• Hypertension Control Clinic
• Patient moved in area

Do not apply:

• Referral to Hypertension Register — this is reserved for new cases only

C

Pathway C: Old Unregistered Case

Patient with known HTN who was never formally registered before

Criteria:

• Patient has known hypertension from prior records
• Never previously registered in any facility's NCD system
• Not a new diagnosis and not a transfer-in

Apply codes:

• Hypertension Control Clinic

Do not apply:

• Referral to Hypertension Register — this patient is not a new reporting cohort
• Patient moved in area — this is not a transfer-in

Note: Because this patient was never registered, there is no prior facility to transfer from. Treat as a baseline active case under Hypertension Control Clinic and complete the HTN Overview template for longitudinal tracking.

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Ongoing Case Monitoring: Case Status Update

When a patient's follow-up status changes, add one new code and keep all prior codes intact.

Status Change Reference

Add one new code per event. Keep all existing codes.

DefaulterDefaulter

Add → Did not attend hypertension clinic

Transfer OutTransfer-Out

Add → Patient has moved away

Out of ZoneLuar Kawasan

Add → Out-of-zone hypertension code used by clinic

DeceasedDied

Add → Patient died

Critical Rule

Always keep the permanent baseline code: Hypertension Control Clinic. When patient status changes, add a new code.