TB Documentation Standards

This page covers TB Clinic-specific documentation (templates, DOTS logging, contact tracing, confidentiality). General CCMS documentation standards are covered in OPD Documentation Standards↴.

General Documentation Procedure (SystmOne)

General Documentation Principles

• Always use designated TB templates as listed below
• All visits, procedures & assessments must include a timestamp and be linked to a TB-coded episode. This happens automatically when using TB templates.
• Ensure consistency between manual forms and CCMS entries. To achieve this, all documentation must first be entered into the CCMS system and then printed for physical filing.
• Always follow the general best practice recommendations for documentation purposes.
• Ensure patient identity is verified per clinic-wide Patient Identification & Safety protocol before documenting.
• Do not skip fields marked as important in the template (e.g., symptom history, weight, DOTS)
• Avoid free-text notes unless necessary - use structured field

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Documentation Templates

Doctor Templates

New TB Case Template

Diagnosis confirmation and treatment initiation.

Follow-Up TB Case Template

Monthly progress review, sputum/CXR tracking, and milestone updates.

Contact TB Template

Contact evaluation and screening outcomes.

Saringan Klinikal Tuberkulosis

High-risk group (HRG) clinical screening.

MA and Nurse Templates

JKN Assessment and Procedure

Vital signs and procedural documentation entries.

Saringan Klinikal Tuberkulosis

Symptom-based TB screening workflow.

TB Index Case Contact Entry

Contact linkage and registration details.

DOTS Daily Log

Observed dose, adherence issues, and follow-up notes.

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Doctors Responsibilities

Action	SystmOne Template
New TB case diagnosis & start of treatment	New TB Case Template
Monthly reviews, sputum/CXR results, milestone checks	Follow-Up TB Case Template
Contact screening and evaluation	Contact TB Template
TB screening for HRG or new clinic referrals	Saringan Klinikal Tuberkulosis
Recording TB Contact List	TB Index Case Contact Entry (within New TB Case Template)

Doctors are responsible for accurate and structured entry of clinical data related to all tuberculosis (TB) cases. SystmOne documentation must reflect the true clinical picture and fulfill both clinical governance and reporting needs (e.g., for audit, clinical reporting, ISO compliance).

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Medical Assistant & Nurses Responsibilities

Action	SystmOne Template
Vital signs, assessment during follow-up	JKN Assessment & Procedure
Clinical TB screening (e.g., Mantoux, symptom review)	Saringan Klinikal Tuberkulosis
Recording TB Contact List	TB Index Case Contact Entry (within New TB Case Template)
Screening of high-risk groups (HRG)	Saringan Klinikal Tuberkulosis (HRG)
Daily DOTS supervision & medication adherence	DOTS log entries under patient record

1. Use appropriate procedural templates for each clinical task performed e.g., Mantoux test, sputum collection, DOTS administration.
2. It is compulsory for the medical staff to record and register all TB contacts of an index case in SystmOne, ensuring proper linkage and scheduling for contact screening.
3. All administered injections, sputum sample collection or patient education sessions must be logged in SystmOne.
4. Ensure DOTS process is documented daily, including:
   • Patient attendance
   • Medication taken (observed)
   • Any missed doses and patient explanation
   • Side effects or complaints
   • Next day TCA
5. Mantoux Test:
   • Record both the test date and reading date (within 48-72 hours)
   • Enter measurement in mm and interpret result according to guideline
6. Contact Screening:
   • Record each contact linked to the index case in the designated TB clinic template in SystmOne
   • Escalate abnormal results to MO immediately
7. High-Risk Group (HRG) Screening:
   • Follow clinic protocol for symptom-based and diagnostic-based screening
   • Record CXR results, symptoms, AFB sputum status
   • In addition to performing and documenting HRG screening procedures, Medical Assistants and Nurses are responsible for inter-departmental coordination and oversight to ensure HRG screening is systematically conducted across all relevant clinic units.
8. Defaulter Tracing:
   • Initiate tracing steps within defined timeline (Day 1-3)
   • Document each action (call, letter, home visit)
   • Update outcomes (retrieved, unreachable, LTFU) in SystmOne

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Confidentiality & Data Security in Documentation

• TB patient data is confidential and sensitive under national infectious disease policy.
• Access to SystmOne must be role-based:
  • MO/FMS: Full clinical access
  • MA/Nurse: Clinical entry only (no deletion)
• Printed TBIS cards and appointment logs must be stored in locked cabinets.
• Never share screenshots or identifiable records via WhatsApp or social media.
• Any data export for audit or reporting must be anonymized.