Fever Clinical Documentation in CCMS

All Fever Clinic encounters must be documented in SystmOne to ensure clinical traceability, infection control surveillance & MOH notifiable disease compliance.

Scope Boundary

This page covers Fever Clinic-specific documentation — JKN fever templates, e-notis notification, and infection-control surveillance. For general CCMS documentation standards (template selection guide, documentation checkpoints, coding rules, checklist updates, and common errors), see OPD Documentation Standards↴.

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1. CCMS Templates & Modules Used in Fever Clinic

For Health Assistants (PPK)

Template

Registration Module, Assessment Template, Appointment Module

Vital Signs

Blood pressure, heart rate, respiratory rate, temperature, SpO2, pain score

Anthropometry

Weight, height, BMI measurements

Screening

• Initial screening checklist
• Epidemiological exposure history
• Risk screening for severe illnesses

For Medical Officers (MO)

Template

JKN Fever & Dengue Assessment Template

Fever History

Fever onset, duration, and primary complaints

Red Flags

Shortness of breath, rashes, pulse pressure

Exposure

Travel history and exposure risk

Notifiable Diseases

MOH-reportable guidance: Dengue, COVID-19, MPOX, MERS-CoV

Additional templates have been created for cases such as MERS-CoV, MPOX, URTI, etc.

Coding Note: All diagnoses must use SNOMED-CT↴ codes before saving the entry. For coding guidance and common errors, see the OPD Documentation Standards↴ page.

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2. Mandatory Documentation Requirements

Patient Demographic Info & History

Update patient demographic details. Complete history of presenting complaint, fever duration, pattern, associated symptoms, travel history, contact history, and risk factors

Physical Examination

Documented examination findings including vital signs, general appearance, and system-specific findings

Diagnosis

Accurate clinical diagnosis with SNOMED-CT coding before saving the entry

Investigations

Diagnostic request entries completed in SystmOne for blood tests or radiology — results linked back to the encounter

Management Plan

Medications prescribed via PHIS integration — no printed medication slip required. Checklist updated upon completion.

Referral

If referred to ED, use the auto-generated referral letter within the SystmOne template

Notification

If infectious disease is suspected or confirmed, formal e-notis registration must be completed and the designated IK at PKD Muar alerted