Documentation of clinical encounters with patients in a uniform and consistent manner is critical for individual follow-up as well as for facility-level monitoring and evaluation, quality improvement, and research. NCD-specific clinical forms can help facilities achieve higher quality data.
Medical informatics tools
The quality of NCD-specific clinical forms depends on several factors:
- User friendly: The format, length, and sequence of a clinical form should allow the clinician to efficiently complete the form in a step-wise fashion.
- Essential data: Clinical and M&E teams should discuss what data is essential and needs to be collected at each patient encounter.
- Data transcribing: If data will be manually entered into an electronic database, then the form should include prompts which produce data that can be clearly and easily transcribed. This includes tick boxes and clearly defined spaces for entering numeric data. Data officers must also be well-trained to prevent data transcription errors.
- Clinician Training: Finally, the quality of the forms is valuable only if the forms are properly filled. Thorough training of clinicians on how to fill the forms and why it is important are key. M&E-driven quality improvement can establish a feedback loop to reduce errors in filling of forms.
Daily registration of patient visits is a critical first step in monitoring the NCD clinic volume and patient demography of an NCD patient. The following tool is a sample registry utilized by the Malawi Ministry of Health – Neno District in collaboration with Abwenzi Pa Za Umoyo (APZU), PIH’s sister site in Malawi.
Routine clinical forms
The “Mastercard” approach has been designed and utilized by the Malawi Ministry of Health – NCD Unit, APZU and PIH – Liberia. This concise form provides a more consolidated approach for clinics looking to establish routine data collection for each visit.
In Rwanda, the Rwandan Ministry of Health and Inshuti Mu Buzima implemented a more detailed approach to clinical forms, which includes four different form types.
Two unique forms which serve patient tracking purposes are the call-back log form and the exit form. The call-back log form is applied if a patient misses an appointment. Nurses then call the patient and document the outcome of the call. The exit form is applied if the patient is deceased, declines further care, transferred out or lost to follow-up (LTFU). LTFU is defined by having no clinic visits during a 6-month period which includes not being reachable via monthly phone calls and a home visit.
Mentorship and Enhanced Supervision of Health Care (MESH)
The following clinical checklist forms are to be completed by mentors during their observation of nurse mentees providing routine care. Forms were produced by the Rwandan Ministry of Health and IMB.
Several forms have been established by Malawi Ministry of Health – NCD Unit and APZU in order to facilitate the implementation and monitoring of community-based screening activities.
Electronic Medical Record (EMR)
Establishment of an EMR can greatly enhance the data collection capacity as well as its value in applications to patient care, M&E and research. The following is a list of essential equipment and human resources which will allow for successful implementation of an EMR system.
Once the essential equipment and human resources are attained, a carefully planned sequence of implementation steps will need to be executed. The following implementation process measures (IPM) tool is a step-wise checklist of essential milestones.
EMR as a tool for tracking patients
As described in the IPM tool, a successful NCD EMR requires programming of all forms. These electronic forms then become the foundation for routine data collection which can occur via direct entry from the clinician or through transcription of paper forms into the EMR via a data officer.
Routine data collection enables the EMR to produce reports which can also serve as a tool for patient tracking. For example, EMR can produce routine reports listing all patients who have a missed appointment visit. This list can then serve as a resource for routine patient tracking to improve adherence. However, the mobilization of the paper chart through the proper departments of the health facility is not simple. The following implementation flow chart illustrates one approach to allowing paper charts to be transcribed into the EMR while carefully tracking patient outcomes. Of note, the complexities of this approach can be avoided via direct entry (point of care) by the clinician into the computer or tablet.
Another approach to patient tracking from the PIH site in Malawi is described in the second document below. This Tracking Retention and Client Enrollment (TRACE) program incorporates community health workers to respond to regularly produced reports from the EMR.