NCD Clinical Workflow

Patient Flow Summary

1

1. Patient Arrives at Triage

Booked

• Patient presents with NCD booklet and confirmed TCA date
• Direct patient to OPD Registration Counter

NCD Book Digitalized

2

Take Registration Queue Number

• Patient proceeds to sit in the registration waiting area

3

Registration Counter Call Patient

Arrived

• Call the patient's QMS number
• Key-in demographic and billing details (if applicable)
• Issue standard clinic checklist
• Assign QMS number and direct patient to NCD Unit waiting area

4

NCD Room: Vital Signs & Anthropometry

In Progress

• Use JKN Assessment & Procedure Template↴ to record vital signs & anthropometry data
• Identify & set current patient NCD status: active, defaulter, new-case, transfer-in
• Utilize the JKN DM/HTN Checklist Template↴ to ensure all necessary procedures are completed
• Record latest blood test results using the Lab Recording Template↴
• When applicable, proceed with fundus camera, visual acuity, foot care assessment & diabetic education

5

Fundus Camera Examination

In Progress

• Use Fundus Camera Template↴
• Enter data and perform stratification for retinopathy risk

6

Foot Care Assessment

• Use Foot Care Assessment Template↴
• Document findings and perform risk stratification

7

NCD Education

• Refer to JKN DM/HTN Checklist to identify outstanding counselling items
• Provide targeted education & counselling

8

Feedback for Doctor

• Document findings, exam interpretation & education summary in SystmOne
• Use Reminder Feature↴ in SystmOne to communicate with doctors & other team members

9

Auto-Allocate to Doctor's Room

Finished

• Auto-allocate patient to Doctor's Room (1-6) for further consultation, assessment & treatment by doctors
• Instruct patient to proceed to Waiting Area 17

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Friday New-Case Workflow

Friday AM: New Cases Only

Friday mornings are reserved for new NCD cases. These appointments are scheduled with extended time to allow the NCD team to complete full complication screening (fundus camera, foot care assessment, and baseline laboratory investigations) before the doctor consultation. Follow-up cases are not booked on Friday mornings.

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Visual NCD Patient Workflow

NCD Flowchart

• Here is the algorithm and flowcharts for NCD patient in the clinic.
• Ensure all staff members adhere to the SOP provided.

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Follow-Up and Appointment Scheduling

Follow-up planning for NCD patients is crucial to ensure continuity of care & timely reassessment based on clinical status. The intervals and investigation schedules below are NCD-specific. For general appointment mechanics (SystmOne rota, TCA card issuance, slot limits, and reschedule rules), see OPD Appointment & TCA Management↴.

Follow-Up Interval Guidelines

Uncontrolled cases

2 – 6 weeks

Stable NCD cases

3 – 6 months

New NCD Case ✅

1 - 3 months on Friday
Friday gives NCD team ample time to complete complication screening.

Out-of-Zone Case ❌

To transfer-out within 1-2 months or next TCA.

Investigation & Procedure Scheduling

HbA1c

Every 6 months

CVD Screening (RP, LFT, FSL, UA)

Every 6 months

Foot Care

Every visit if possible

Fundus Camera

Every 6 months

Diabetes Education

Based on checklist and case requirement

REMARKS

• All appointment dates must be keyed into SystmOne with accurate unit assignment
• Patients must be issued a TCA card or label slip after appointment scheduling
• Missed appointments should be monitored, and follow-up actions coordinated by the NCD team
• Friday AM is new-case only — see OPD Appointment Rules↴ for consolidated scheduling across all units

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Defaulter Tracing Protocol

When an NCD patient misses a scheduled appointment, the following NCD-specific escalation pathway is activated.

Day	Action	Responsible
Day 1 (missed TCA)	Phone call to patient; document outcome in SystmOne	NCD team nurse / MA
Day 7 (no show)	Send reminder letter via mail or WhatsApp	NCD team nurse / MA
Day 14 (still no show)	Home visit if justified; flag as potential defaulter	NCD team + PKD coordination
Day 30+	Mark as Defaulter	NCD Team / MO

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Escalation to FMS & Special Services

General Indications for FMS Referral

Newly diagnosed but complex cases

• Young hypertension
• Type I DM

Uncontrolled despite standard management

• Diabetes patient with HbA1C >10
• Resistant hypertension
• Uncontrolled BA with risk of severe BA, COAD Group E

Severe or complex cases

• CKD Type IIIB and above
• Multiple comorbidities

Pregnancy with comorbidity

• Pregnancy/pre-conception with pre-existing NCD (DM, HPT, BA, autoimmune disease) – Co-manage with hospital specialist

Diagnostic uncertainty

• Requires specialist opinion for diagnosis or management planning

Supportive Services Referral Criteria

DM-MTAC (Pharmacist)

• HbA1C >10%
• Uncontrolled diabetes
• Polypharmacy
• Adherence issues

Dietitian / Nutritionist

• HbA1C >10%
• Obesity
• Poor glycemic control
• Diet-related issues

Physiotherapy

• Neuropathy
• Limited mobility
• Rehabilitation needs

Quit Smoking Clinic

• Current smoker or recently quit, with motivation

REFERRAL BEST PRACTICE

• Use relevant SystmOne referral templates (e.g., "Refer to DM-MTAC", "Refer Dietitian")
• Use Task Feature to send notification to the respected referral party
• Use the Reminder system in SystmOne to notify the primary doctor of referral outcome or follow-up required
• Referred service units must document outcomes or findings within the same patient profile in SystmOne for seamless visibility