Documentation Quality Implementation

A documentation error is any deviation from expected data recording standards that results in incorrect, incomplete, misleading, delayed, or unauthorized entries. We track these errors not to assign blame, but to understand where our systems, workflows and training need strengthening.

For the foundational principles of CCMS documentation, see the Documentation Principles↴ on CCMS-Wiki.

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Documentation States

Every entry in SystmOne exists in one of four states. Understanding these helps staff choose the right action when an error is found.

Active

The default state. Visible to authorised users and part of the active patient record.

Marked in Error

Entry is moved to the Deleted Items node. It remains auditable but is excluded from active care decisions.

Deleted

Only available in specific modules such as the medication list. The entry is moved to Deleted Items.

Sealed

Entry is locked. Access is restricted to authorised roles only. Used for sensitive or completed records.

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Action Taken to Resolve Error - Implementation Status

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Common Errors at KKBM & Action Taken

The following errors are routinely observed at KKBM. Each row shows the error, where it occurs & what we have implemented to address it.

Error type	Example / description	Commonly seen in	Resolution
1. Incorrect patient demographics	Wrong ethnicity, address or demographic data key-in	Registration Counter	Update Demographic Detail 2-identifier protocol↴
2. Duplicate patient record	Patient registered twice under slightly different details	Registration Counter	Safety Cont. Procedure 2-identifier protocol↴
3. Wrong patient registration	Newborn incorrectly registered under mother's IC	Registration Counter	Safety Cont. Procedure 2-identifier protocol↴
4. Incorrect patient record documentation	Notes entered on the wrong patient's record	All Clinical Areas	Mark In Error 2-identifier protocol↴
5. Medication prescription error	Wrong medication, dosage, route, or patient	Doctor's room	Stop Medication 2-identifier protocol↴ PhIS liaise
6. Wrong clinical data entry	Incorrect BP, temperature, or other vitals keyed in	Vital Signs, NCD, Fever Clinic, Procedure Room, OPD	Mark in Error↴ Correct Node Usage
7. Wrong test or procedure ordered	Wrong investigation or lab request selected	Doctor's room	Correct Node Usage Template Standardization
8. Wrong vaccination entry	Incorrect vaccine part or batch recorded	MCH Unit	Correct Node Usage Vaccine Template Updates
9. Wrong appointment date or details	Incorrect date or wrong patient booked	Appointment Counter	Correct Node Usage Rota Appt Changes
10. Missed procedure documentation	Procedure done but not documented	Doctors room, Procedure room, NCD, Fever clinic, OPD	Date Re-Entry Template Compliance
11. Auto-allocation to wrong room	Patient auto-allocated to the wrong room or unit	Registration counter, Doctors room	Auto-Allocation Flowchart Workflow Review
12. Mistaken deletion of data	Data removed by mistake	All Users	Date Re-Entry Supervisor Notification Deleted Items Review↴