MCH Documentation Standards

Scope Boundary

This page covers MCH-specific documentation — antenatal and child health templates, Pink Book backup workflow, and MCH appointment administrative standards. For general CCMS documentation standards (template selection guide, documentation checkpoints, coding rules, checklist updates, and common errors), see OPD Documentation Standards↴.

1. CCMS Adoption Context

Implementing SystmOne/CCMS within the MCH (KKIA) Unit presents unique challenges due to the complexity and breadth of maternal and child healthcare services. Unlike other units, KKIA involves not only the transition to digital documentation but also adjustments in workflow, consultation dynamics, and staff coordination.

Clinical documentation, including antenatal and child development records, must follow highly detailed structures. Full implementation of real-time clinical data reporting has not yet been achieved due to system and workflow limitations. The KKIA Unit remains one of the most documentation-intensive areas of the clinic and as such, progressive rollout and continuous staff training are ongoing to ensure safe and complete adoption of SystmOne/CCMS features.

Additionally, this unit is involved in medico-legal responsibilities, particularly related to antenatal and child development records. Some physical documentation, such as the Maternal Health Book (Pink Book), is still required by policy and cannot be fully digitised at this time. To maintain continuity of care, all entries documented in SystmOne are printed and attached into the patient's physical book or given as a printed copy during the visit.

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2. Common MCH Cases & SystmOne Templates

Case Type	SystmOne/CCMS Template Name
1. Antenatal Booking	Nurse: JKN Antenatal Booking Template for Nurses V2 Doctor: JKN Antenatal Review Template for Doctors V3
2. Antenatal Follow-Up	Nurse: JKN Antenatal Follow-Up Template for Nurses V2 Doctor: JKN Antenatal Follow-Up Template for Doctors V2
3. Antenatal Scans (MO)	Antenatal Ultrasound Template
4. Delivery History	Delivery History Template V2
5. Antenatal Advice & Consultation	Antenatal Care Advice Template
6. Postnatal Care	Postnatal Review Template
7. Family Planning & Contraception	Contraceptive Review / Jadelle Template
8. Pre-Pregnancy Care	Pre-Pregnancy Care (PPC) New Case & Follow-Up Template
9. Child Routine Assessment	Nurse: Child Health Assessment for Nurse Template V3 Doctor: Child Health Review for Doctors V1
10. Child Vaccination	Nurse: Child Vaccination Template (included in Child Health Assessment Template)
11. Jaundice Monitoring	Nurse: Neonatal Jaundice Monitoring for Nurse Template V1 Doctor: Neonatal Jaundice Review for Doctors Template V1
12. Procedure & Screening Template	Cervical Smear Documentation Template Pemeriksaan Klinikal Payudara (PKP) Template Virtual Consultation Documentation Template

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3. Documentation Requirements in SystmOne

• Nurses and health assistants are required to either use the Maternal Health Assessment Template or complete the required vital signs and anthropometric fields embedded within each relevant case-specific template for maternal and child health.
• Doctors and nurses must select and complete the appropriate case-specific clinical template based on patient presentation (refer to Section 2). This includes:
  • Antenatal follow-up
  • Postnatal care
  • Child development assessments
  • Family Planning & Contraceptive consultations
  • Pre-pregnancy screening
• All mandatory fields in the template must be completed before the record is saved.
• Each entry must comprehensively document:
  • Presenting complaint and clinical findings
  • Ongoing risk factors (e.g., GDM, anemia, low weight gain)
  • Interventions given (e.g., iron therapy, immunization)
  • Health education provided (e.g., family planning advice)
  • Follow-up plan (e.g., TCA date, referral to higher center)
• If the case involves risk (e.g. uncontrolled BP in antenatal visit), escalation must be documented and a plan clearly noted.
• Printouts of completed documentation are to be issued and attached to the Maternal or Child Health Book to ensure continuity of care (1 copy for patient's record and another for clinic usage).

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4. Pink Book Backup Workflow

The Maternal Health Book (Pink Book) remains a patient-held medico-legal record and a continuity tool.

Who Updates the Book

The attending nurse or doctor ensures that the latest SystmOne printout is attached to the Pink Book before the patient is discharged.

What to Attach

• Latest antenatal or postnatal assessment printout
• Investigation results (Hb, urine, ultrasound summary)
• Medication list and follow-up plan

If the Patient Forgot the Book

• Document in SystmOne that the Pink Book was not brought
• Remind the patient to bring it for every MCH visit
• Issue urgent results or plans on a temporary slip if clinically necessary

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Downtime & Recovery

For system downtime procedures, interim documentation, and reconciliation deadlines, refer to the clinic Business Continuity Plan↴.