Closing a Clinical Record

To complete a service, close the clinical record.

When you close a clinical record you perform one of the following actions:
  • Complete the service
  • Pause the service so it can be completed by another provider
  • Close the service without providing a service and record your access in the database. Unless you opened an existing service or booking (when you opened the clinical record) your service comment is also ignored. No patient or consultation details are sent to My Health Record or MeHR.

Completing a service

When you complete a service, service details are sent to My Health Record or MeHR where enabled and selected.

If your health service is integrated with Medicare, you can submit an electronic claim when you close a service.

To complete a service:
  1. In the Clinical Record, click Close iconClose.
  2. If there are any prescriptions that have not been finalised or printed, you are prompted to finalise the prescriptions. To finalise the prescriptions:
    1. In the Confirm window, click Yes.
    2. In the Finalise Prescriptions window, select the prescriptions and the required medication request and print options and click Finalise. For more information, see Finalise Prescriptions.
  3. If you use medication requests and the latest non-cancelled request was stopped today and a pickup location isn't set, or there is a pickup location set but a medication request has never been created, you are prompted to create a medication request.
    • In the Confirm window, if you want to create a medication request for the patient:
      1. Click Yes. The Medication Requests window is displayed.
      2. Add a new medication request as required. For more information, see Medication Requests.
    • If you don't want to create a medication request, click No.
  4. In the Service exit window, in the Service message field, enter a comment about the service to be displayed in the Service Record window.
  5. If you want to upload service records to My Health Record, set Send Event Summary to My Health Record and Send Shared Health Summary to My Health Record. If the patient has consented to sharing information with My Health Record, these options are set. See My Health Record Summary Documents below for more information.
  6. For NT patients, if you want to upload their service records to MeHR, set Send to the MeHR. If the MeHR to My Health Record Transition module is enabled, and you want to upload service records to My Health Record, set Send Event Summary to MeHR and Send Shared Health Summary to MeHR. See MeHR below for more information
  7. Click Yes - This service is now complete.
  8. The Service Record window is displayed. The service message from step 3 is displayed on the Detail tab.
  9. If Medicare claiming is enabled, on the Medicare tab:
    • If reception handles payment and claims at your health service, click Claim later.
    • If you submit claims yourself, select the relevant Medicare items and click Claim now.

The service finishes.

If you finalised any prescriptions, they are assigned a script number. If you chose to print any prescriptions or medication requests they are printed to your default printer.

If sharing with MeHR is enabled, the Current Health Profile for the patient and a Medical Event Summary for the consultation are sent to the MeHR.

If sharing with My Health Record is enabled, a Shared Health Summary and an Event Summary for the service are sent to My Health Record.

In the Service Recording window, the service has a status of Finished.

Pausing a service

If you have completed your contact with a patient but they will be going on to see another provider, you can pause a service.

To pause a service:
  1. In the Clinical Record, click Close iconClose.
  2. If there are any prescriptions that have not been finalised or printed, you are prompted to finalise the prescriptions. To finalise the prescriptions:
    1. In the Confirm window, click Yes.
    2. In the Finalise Prescriptions window, select the prescriptions and the required medication request and print options and click Finalise. For more information, see Finalise Prescriptions.
  3. In the Service exit window, in the Service message field, enter a comment about the service to be displayed in the Service Record window.
  4. If you want to upload service records to My Health Record, set Send Event Summary to My Health Record and Send Shared Health Summary to My Health Record. If the patient has consented to sharing information with My Health Record, these options are set. See My Health Record Summary Documents below for more information.
  5. For NT patients, if you want to upload their service records to MeHR, set Send to the MeHR. If the MeHR to My Health Record Transition module is enabled, and you want to upload service records to My Health Record, set Send Event Summary to MeHR and Send Shared Health Summary to MeHR. See MeHR below for more information
  6. Click No - Patient will see another provider.
  7. The Service Record window is displayed. The service message from step 3 is displayed on the Detail tab.
  8. If Medicare claiming is enabled, on the Medicare tab:
    • If reception handles payment and claims at your health service, click Claim later.
    • If you submit claims yourself, select the relevant Medicare items and click Claim now.

The service is paused.

If you finalised any prescriptions, they are assigned a script number. If you chose to print any prescriptions or medication requests they are printed to your default printer.

If sharing with MeHR is enabled, the Current Health Profile for the patient and a Medical Event Summary for the consultation are sent to the MeHR.

If sharing with My Health Record is enabled, a Shared Health Summary and an Event Summary for the service are sent to My Health Record.

In the Service Recording window, the service has a status of Paused with a count in minutes of how long the service has been paused.

MeHR

If the MeHR module is enabled and the patient is registered with MeHR, choose whether to send details of this consultation to the MeHR.

Send to the MeHR is disabled if there is a new Confirmed Pregnancy or Antenatal Check-up clinical item recorded against the service. Instead, in the Confirmed Pregnancy clinical item, if Send Antenatal Report to MeHR is set, the information is sent to MeHR (see MeHR Antenatal Reports for more information).

If MeHR to My Health Record Transition is enabled, the option to send information to the MeHR will not be available if the patient has a My Health Record or the provider has access to the My Health Record.

If the MeHR to My Health Record Transition module is turned on and the patient has an MeHR but not a My Health Record, Send to the MeHR is replaced with Send Event Summary to MeHR, and Send Shared Health Summary to MeHR. These options create My Health Record documents as normal, but send them to MeHR.

My Health Record Summary Documents

To upload summaries to My Health Record, the following requirements must be met:

If these criteria are met, and the patient consents, a Shared Health Summary and an Event Summary for a service are generated when a service is complete.

The Shared Health Summary and Event Summary options are set if:
  • The patient has consented to sending documents to the My Health Record, that is, in Patient Biographics, Patient consents to My Health Record uploads is set. If the patient has not yet given consent or has declined consent, these options are not set.
  • For Shared Health Summaries, both:
    • The patient has consented to upload documents (or if the Mehr to My Health Record Transition module is enabled, the patient has not declined consent to upload documents)
    • Data that will be included has been recorded or amended (for example, an immunisation has been recorded, a summary clinical item added, a current medication stopped, and so on)

If My Health Record Access is enabled in both System Parameters and in User Groups but one of the other conditions is not met, a My Health Record Help button is displayed instead of the Shared Health Summary and Event Summary options.