Purpose:
To standardize the documentation process for Voluntary Male Circumcision (VMMC), ensuring that all relevant patient information is accurately recorded and easily accessible. By following this SOP, healthcare providers can ensure that patients receive timely and appropriate care, facilitate continuity of care, and support data collection for quality improvement initiatives. This SOP also aims to streamline workflows and reduce the risk of errors in patient records.
Follow the step for documenting VMMC service in Outpatient:
Log in Outpatient.
Search for the patient file. You can search for the patient file using any of the following methods:
Visits - This shows you a list of all visits for the day. If patients are not checked out in the system, the visit automatically gets checked out after 24 hours.
All Visits - Here you can search for patients using Phone number or Evax ID only. It shows you patient visit history.
Recent Activity - This shows you a list of files that you have recently opened and the time you accessed the file.
Go to the visit screen and click the plus icon on services to add a VMMC service.
BACKGROUND TAB
Background Section
Relationship- Select you relationship status.
Referral - Select the facility that referred the patient.
Treated for STI in last 3 months - Answer if patient has had treatment for STI in last 3 months.
Haemophilia or bleeding disorder - If patient has had Haemophilia or bleeding disorder select YES, else select No.
Diabetes - If patient has had Diabetes select YES, else select No.
On ART - If patient is on ART select YES, else select No.
Complaints Section
Urethral discharge - If patient has urethral discharge select YES, else select No.
Genital sore/ulcer - If patient has Genital sore/ulcer YES, else select No.
Pain on erection - If patient has Pain on erection select Yes, else No.
Pai on urination - If patient has Pain o urination select Yes, else No.
Swelling of scrotum - If patient has Swelling of scrotum select Yes, else No.
Difficulty retracting foreskin - If patient has difficulty retracting foreskin select Yes, else No.
Other - Specify other complaints.
HIV Test History
Ever tested for HIV? - If patient has ever tested for HIV select YES, else select No.
Previous HIV Test Date - If patient has ever tested for HIV enter the
Previous HIV Test Result - Enter HIV results.
Was the patient tested today? - If patient was tested today select YES, else select No.
Today's HIV Test Result - Enter HIV test result.
Referred for CD4 test - If patient has been referred for CD4 test select YES, else select No.
Surgical History
Surgical History - Enter surgical history if patient has had any before.
EXAM TAB
Physical Exam Section
Perform the physical exam and answer the question.
Other - Specify other observations made during the examination.
Examined by - Enter the person who did the examination.
Current Medication Section
If patient is currently taking any medication, you can list them here.
Other Details Section
Enter other details that are observed during examination. These are not just focusing on the genitals but on the overall body.
Allergies Section
Specify if patient is allergic to anything.
PROCEDURE TAB
Preparation Section
Document medication used during preparation.
Operated By - Select the name of the person who operated.
Assisted By - Select the name of the person who assisted.
Sutured By - Select the name of the person who sutured.
Procedure Notes
MC Done- If male circumcision has been done, click Yes, else click No.
Document the medication used to on procedure.
Suture Method - Enter the name of the person who sutured the patient.
Diathermy - Diathemy is supposed to be 18.
Suture Item - Enter the item that was used on suture.
Procedure Method - Enter the procedure method.
Consent Section
Patient should read and consent to the procedure. If they decline, you should not proceed with the procedure.
Time & Motion
Procedure Started - Enter the time procedure was started.
Procedure Ended - Enter the time procedure ended.
POST OP TAB
Adverse Events Section
For the adverse events select the relevant option.
Recovery Details Section
Hold In Recovery and Monitor (minutes) - Enter number of minutes required for patient to wait for recovery after surgery.
Follow-Up (days) - Enter the number of days needed for the patient to return for check-up
Bandage Loosened - Check the bandage to see if is loosened.
Urination Following Surgery - Check if patient urinated after the surgery.
Instructions -Enter any instructions.
FOLLOW-UP TAB
Follow-Up Appointment
Schedule a follow up appointment when patient will come for review.
Vitals Section
Enter vitals taken during the VMMC procedures.
SERVICE PROVIDER
Click "Select Service provider" link, followed by clicking by clicking "Set As Me" to show your name as the service provider.
Finally .click the "Submit Review" button to send the service template for review.