Clinical Item Type Properties

To display Clinical Item Type Properties, in the Clinical Item Type Maintenance window, double-click an item or select an item and click Edit row iconEdit Row.

Note: Items with a record number of 1,000,000,000 or greater are centrally maintained by Communicare and have only limited local editing rights.

General tab

On the 'General' tab, set the basic properties of a Clinical Item Type, including:
  • 'Formal Terms' - enter the name or Rubric for the item, which isused to give a detailed and exact definition of what the item means and when it should be used. For example, ?Pregnancy or Abrasion;corneal.
  • 'Natural language' - a more natural description of the term. It can be used in letters, for example, where a more user-friendly term is required.
  • 'Definition' - describe the clinical item unambiguously, so that misuse through misunderstanding does not occur. The definition may contain drawings and pictures.
  • 'Class' - select what sort of thing the item is, for example, a record of a Procedure which has been performed, or a Condition which has been diagnosed.
  • 'Topic' - select the topic, that is an arbitrary classification which helps organise a patient's clinical information.
  • 'Recallable' - determines if the item can be used as a recall. This option is only visible for items with a class of Procedure, Immunisation or Referral.
  • 'Allow Recall Expiry' - determines if a user can set a future expiry date for a recall of this type. This option is only visible for items with a class of Procedure, Immunisation or Referral.
  • 'Enabled' - determines if the item can be added to a Clinical Record. Disabling an item does not remove it from patient files, it simply prevents it from being used to record new information. Centrally disabled items cannot be enabled locally.
  • 'Cost' - optional value used for reporting and analysis.
  • 'Viewing Right' - right required to view the clinical item.
  • 'Record for occurrence' - record a clinical item with a date and time, or as date only. The default is date only.
Click 'Advanced' to display the following options:
  • 'Export Code' - a code that may be used when exporting data to another system. For example, it is used when exporting data to the CCDM, in which case it holds an ICPC code.
  • 'System Code' - an internal code used by Communicare to identify items that are used in calculations. Leave blank unless instructed otherwise.
  • 'Record No.' - Communicare's internal reference number.
  • 'Critical Referral' - enabled when a Referral type item is added or edited. Use to set the item as critical. The standard referrals report can report on these items.
  • 'Item Interval' - the interval required since the last completed clinical item in order to be able to complete the new clinical item. It is used to allow a clinic to define a required period in which an item should be completed. The item can only be completed at the end of the required interval. If an attempt is made to complete this item during the item interval, the item generates a recall with the comment Cannot complete before DD-MON-YYYY.
  • 'Letter Type' - the letter type to be used when adding this clinical item to the patient's record. If not set, 'Save & Write Letter' is not be visible.
  • 'Rule Code' -
  • 'Picture' - add a picture for the clinical item type to the 'Picture' tab of the Clinical Terms Browser. The image must in the format bmp, ico, emf or wmf and be no larger than 60x60 pixels. You must also add an image for the related Clinical Item Topic.
  • 'Medicare Benefits Schedule':
    • 'MBS Item No.' - the MBS item to be claimed when the clinical item is completed. If there is a number entered here, only a provider with a Provider Number will be able to complete this item, and on completion, the specified item is automatically selected for the provider to claim electronically. If an item is completed by a provider who doesn't have a Provider Number, the item generates a recall with the comment 'Only a doctor can complete this'.
    • 'Claim Interval' - the interval for the MBS item, used when Medicare Australia says that the MBS item cannot be claimed more often that the Claim Interval. If an attempt is made to complete this item by a provider with a Provider Number within the claim interval, the MBS item is not automatically selected for claiming.
  • ICPC 2 Plus:
    • Code and Term - ICPC-2 PLUS code for this term. If a clinical item doesn't have a complete code, it doesn't appear on reports that look for this code and decision support is not available.
  • SNOMED
    • Concept Id and Name - mapping between ICPC-2 PLUS code and the SNOMED concept. When you enter a valid Concept ID of 6-18 digits, Communicare tries to pull the correct concept name from the National Terminology Service and update the Concept name and status. The status can be Invalid, Verified or Not Verified. Only verified concept Ids have a concept name. You cannot save invalid Concept Ids. If a clinical item doesn't have a SNOMED concept Id, it doesn't appear on reports that look for this concept Id. Central items mapped to SNOMED CT are mapped centrally; map only local clinical items using these settings.
    • 'Re-verify SNOMED Concept Id' - set to force the validation call to verify the Concept Id again.

Keywords & Qualifiers tab

The keywords grid lists the terms that can be used to locate this item.

The qualifiers grid lists any qualifiers that are linked to this item. Qualifiers add additional meaning to a Clinical Item Type. A Clinical Item Type can have

any number of qualifiers associated with it. For example, the clinical item Pregnancy;confirmed may have associated qualifiers such as Date of LNMP, Gestation, Foetal heart rate, and so on.

The qualifier types table shows the following information:
  • 'Order' - a number used to sort the qualifiers
  • 'Qualifier' - qualifier term
  • 'Unit' - units in which the qualifier is measured, for example, Date, weeks, bpm.
  • 'Required':
    • Qualifiers cannot be marked as Required if the clinical item type is not recallable, nor can they be used if the clinical item type is a referral.
    • If a qualifier is not required, it cannot have a required interval.
    • When a clinical item is recallable and has required qualifiers, making the item not recallable clears the required flag on the qualifiers.
    • When designing a clinical item that has required qualifiers, note that the behaviour of that qualifier does not commence until the day after the qualifier was enabled. To see the effective date, right-click and select 'Show Hidden Columns'.
  • 'Highlight Blank' - set to highlight a qualifier when it has no data. This is useful to draw attention to important values on very long forms.
  • 'Enabled' - use to hide a qualifier that has been used in the past, but is no longer needed. No patient data is lost and the data is visible when older items are edited. However, the qualifier will not appear for use in the future. Disabled qualifiers are displayed in grey.
  • 'Min Age' and 'Max Age' - determine whether the qualifier should be shown in the clinical item. A patient who is below the minimum age or above the maximum age will not have the qualifiers shown when that item is added.
  • 'Show Tab' - determines whether this qualifier should appear on the clinical item as a new tab. Note that this field can only be set for qualifiers that are of the Unit type Title.
    • This field only applies when the 'Allow Tabs in Clinical Items' system parameter is on. This field cannot be changed for qualifiers on centrally maintained clinical items.
    • Title type qualifiers do not collect data. They are displayed in bold in this window to facilitate design.
    • Where a qualifier is sex-specific, the row is coloured pink or blue depending on the sex. Qualifiers with a sex that does not match that of the patient are not displayed when the clinical item is added.

To edit a keyword, click 'Edit Keyword Table'.

To edit a qualifier, click 'Edit Qualifier Types'.

Keywords can be added, deleted or changed in the top grid. The bottom grid displays all the clinical item types that use the keyword selected in the top grid. The bottom grid can be used to add or delete clinical item types to a keyword. See Clinical Item Keywords for more information.

Groups tab

The Groups tab shows the groups to which the clinical item type belongs, for reporting and analysis purposes.

To add groups and edit or delete existing groups, click 'Edit Groups Table'.