Table 1.

Scoring criteria used to compare documentation in paper-based charts used in the management of three NCDs in BHC. The first set of scoring criteria (A) were used to compare clinical documentation before and after the introduction of RSTs. The second set of criteria (B) were used as control, to score chart documentation irrespective of template use.

A. Scoring dimensions (Criteria for scoring information in charts, whether templates used or not)
Dimension	Hypertension	Diabetes	Chronic Respiratory Diseases
General data	Sex	Sex	Sex
	High risk age group	High risk age group	High risk age group
	Visit type (First/Follow-up)	Visit type (First/Follow-up)	Visit type (First/Follow-up)
	HIV status	HIV status	HIV status
		Time since diagnosis	TB status
Assessment	Comorbidity (Diabetes)	Comorbidity (Hypertension)	Diagnosis group (Asthma/COPD/Recurrent obstructive bronchitis)
	Smoking	Smoking	Smoking
	Alcohol use	Alcohol use	Exposure (domestic/occupational)
	Signs of organ damage	Complications of diabetes	Heart disease (COPD) OR Asthma triggers
			Severity/control of symptoms
Testing	Blood pressure	Blood pressure	Chest X-ray
	RBS/RFT/Urine dipstick	RBS/FBS	Peak Flow
		Urine dipstick	ECG/Echo
			Sputum/GeneXpert (COPD only)a
Management	Prescription/Management instructions	Prescription/Management instructions	Prescription/Management instructions
	Counselling	Counselling	Counselling
	Follow-up date	Follow-up date	Follow-up date
	Adherence to medication		Inhaler technique
# Criteria	14	15	17/18

B. Control dimensions (Criteria for scoring information documented outside templates)
Presentation	Notes on presenting complaints	Notes on presenting complaints	Notes on presenting complaints
Vital signs/test results (exact values)	Blood pressure	Blood pressure	Blood pressure
	Heart rate	Heart rate	Heart rate
	Temperature	Temperature	Temperature
	Weight	Weight	Weight
		RBS/FBS
Follow-up	Follow-up instructions	Follow-up instructions	Follow-up instructions
# Criteria	6	7	6

^aOnly scored for COPD cases.