Procedure Room Documentation

Scope Boundary

This page covers Procedure Room-specific documentation — JKN procedure templates, consent protocols, and specimen documentation. For general CCMS documentation standards (template selection guide, documentation checkpoints, coding rules, checklist updates, and common errors), see OPD Documentation Standards↴.

1. Documentation Standards in SystmOne

• Use the JKN Procedure & Assessment Template as the central hub for all standard procedures.
• Specific procedures such as Methadone management and RTK testing have dedicated tabs within the JKN Procedure & Assessment Template.
• Real-time documentation must include:
  • Type of procedure performed
  • Pre- and post-procedure vitals (when applicable)
  • Results of onsite tests (e.g., RTK, vision test)
  • Outcome and patient response
• Checklist updates are required to reflect patient location and procedure completion.
• Doctors must be informed of completed procedures through mandatory documentation in SystmOne. Verbal handover alone is insufficient for audit traceability.
• Attachments such as RTK results or images may be uploaded into the patient profile in SystmOne as supporting documentation.

For general coding requirements (SNOMED-CT, ICD-10), checklist update rules, and documentation ownership, see OPD Documentation Standards↴.

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2. Commonly Used Templates

#	Template in SystmOne	Notes / Usage Context
1	JKN Assessment & Procedure Template	Vital signs and anthropometry documentation; shortcut to other templates; subdivided into tabs for Methadone, TB cases, and Wound Care
2	OPD Procedure Template	Document procedures performed in Room 8
3	Emergency Procedure Template	Document emergent procedures and referral-to-hospital cases
4	Prosedur Penjagaan Luka Template	Document wound care dressing procedures performed in the clinic
5	Visualisation Dashboard: Screening & Procedure Metrics	Visualize real-time data on procedures and health screening performed in the clinic
6	Vision Test Template	Document vision test findings
7	Fundus Camera Template	Document fundus camera findings
8	Pre-marital HIV Screening Template	Document patient demographics and test results

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3. Patient Consent Protocol

Medico-Legal Requirement

Appropriate consent must be obtained and documented for every procedure performed in Room 8. Incomplete consent documentation is a patient safety and medico-legal risk.

Verbal Consent

• Verbal consent is acceptable for low-risk procedures such as routine blood taking, IM/SC injections, and nebulization.
• The fact that verbal consent was obtained must be documented in the free-text notes of the JKN Procedure & Assessment Template.

Written Consent

Written consent is mandatory for the following:

• Wound dressing and any procedure involving photography
• Suture-to-open (STO) procedures
• Any procedure with potential medico-legal implications
• Emergency procedures where the patient is conscious and competent to provide consent

Special Circumstances

• Minors or patients lacking capacity: Consent must be obtained from the legal guardian and documented in SystmOne.
• Refusal of treatment: Must be documented in SystmOne with the reason clearly noted. Inform the referring doctor immediately.