The chronic disease register

Clinic, Chronic register. Who is on it on the left; what to record on the right.

Do not sit down and type four hundred patients in. Open the Suggested tab instead: it lists every patient whose recorded diagnoses say they belong on a register and are not on it, and one press puts them there. That is how the register fills itself, from work you have already done.

If you already keep a paper register

Use the Enrol tab and put the real dates in: the day the patient actually started, and when you last saw them. This matters more than it looks. If you leave both blank, everybody you type in this afternoon falls due on the same day three months from now — including the ones you saw last week — and the recall list is useless from the day you first open it.

The review interval

Each register comes with one already set — three months for diabetes and blood pressure, six for asthma — and the screen tells you which guideline that came from, or says plainly when there is no Malaysian guideline for it. Change it for any patient who needs seeing more or less often. Anything between one week and two years is accepted.

Recording a review

1Find the patient on the Register tab.
2Put the date of the review, and say whether the condition was controlled.
3The next review date moves along by itself. Change the interval here if the doctor wants them back sooner.

Control	What it means
Not assessed	Nobody has reviewed this patient since they went on the register. This is not the same as "not controlled", and the reports keep them apart.
Controlled	At target, in the doctor's judgement. Klinira never works this out from a reading.
Partial	Improving, or at target on some things and not others.
Uncontrolled	Not at target. Usually a reason to shorten the interval.

Nothing here is edited. Each review is a new version, and the old one stays with its date and the name of whoever recorded it — the same rule as every other clinical record. "This entry, version by version" at the bottom of the panel is the whole history.

Taking somebody off the register

It takes a reason, and the reason is the whole point. Write what actually happened — moved to another clinic, no longer has the condition — because in three years that sentence is all there is. You can put somebody back on afterwards; a condition in remission that comes back is common, and Klinira will not make you enrol them a second time.

Calling patients back

The Due for review tab. Most overdue at the top, and no condition anywhere on it.

This is the counter's list, and it is worth ten minutes a day. The patient the clinic has most nearly lost is at the top, because if you only get through ten calls those are the ten that matter.

The list does not say what the patient's condition is, and neither does the message. It asks them to come in for their regular check-up; what it is for is said in the room. A WhatsApp message naming the illness sits in a phone that gets forwarded, screenshotted and read over somebody's shoulder on a bus.

"Already contacted" means a message has been prepared for that patient in the last two months. Skip them.
"Already booked" means they have an appointment coming. You can skip them too, but they stay on the list — an appointment can be cancelled, and then the review would be forgotten.
A patient with no phone number on the record cannot be sent anything. Telephone them, or add a number to their record.

Nothing is sent for you. Klinira writes the message and opens your own WhatsApp with it ready; you press send. There is no account of ours anywhere in this.

The two reports

Chronic disease register — how many patients on each register, and how they are doing. "Not assessed" has its own column, so your admin backlog never reads as a clinical result.
Overdue chronic follow-ups — every patient past their review date, with their phone number, ready to print and work down.