Detail tab

The Detail tab displays the clinical items and clinical data that make up a patient's clinical record. The content displayed depends on the type of clinical item or data. Investigations and medications are also listed.

You can select the way in which clinical items about the current patient are listed. Select from the following options:

Item views
  • Class - groups clinical items by the Class attribute (data values), or clinical data of the same type on separate tabs. If a tab is not displayed for a patient, there are no clinical items of that class or clinical data included in that patient's record. The following tabs may be included:
    • Admission - lists all clinical items recorded in Communicare with a Class attribute of Admission.
    • Adverse Reaction - lists any recorded adverse reactions.
    • Alert - in V20.1 and later, lists any recorded structured alerts.
    • Condition - lists all clinical items recorded in Communicare with a Class attribute of Condition.
    • Document - lists all incoming and outgoing documents and letters including referral letters.
    • History - lists all clinical items recorded in Communicare with a Class attribute of History.
    • Immunisation - lists a patient's full immunisation record, that is all clinical items recorded in Communicare with a Class attribute of Immunisation. If this tab is not displayed, no immunisations have been recorded in Communicare.
    • Ix Request - lists all investigation requests.
    • Ix Result - lists all investigation results.
    • Procedure - lists all clinical items recorded in Communicare with a Class attribute of Procedure.
    • Referral - lists all clinical items recorded in Communicare with a Class attribute of Referral.
    • Rx - Administer - lists medications that were administered to the patient.
    • Rx - Prescription - lists a patient's full prescribing record for all time, including regular and once-off prescriptions and medication orders. It also lists all expired and stopped medications that are no longer displayed on the Medication Summary.
    • Rx - Supply - lists medications that were supplied to the patient.
    • SMS - lists all SMS messages sent to the patient.
    Tip: If your site does not use Prescribing, and some medications are still recorded, you may see Acute Medication and Chronic Medication instead of Rx - Prescription.
  • Topic - groups medical or health related data. Use this view to show information about general health or a medical area of interest. Each topic for which the patient has information recorded is displayed on a separate tab. If the patient has no information recorded under a topic, no tab is displayed. For example, if a patient has no information recorded about Child health, the tab for the topic Child does not display. Topics are unique to each organisation. Two special tabs are:
    • Medication - shows prescriptions, administer and supply records
    • Unclassified Documents - shows documents not yet sorted into an appropriate topic
  • Date - the default option that lists all the clinical items chronologically starting with the most recent at the top of the list. Its primary purpose is to see what has happened recently, or for a period in the past.
Tip: The same information can be viewed in different ways. Every clinical item appears under one clinical item class and one topic. For example, if a referral to an ENT specialist is recorded for a patient, it appears both under the class Referral and under the Ear topic.

Communicare retains the last tab viewed for both View by class and View by topic. For example, if the Referral tab is viewed for a patient and a new patient is selected, the Referral tab is initially shown for the new current patient.

Clinical items can be added, changed and deleted, or recalls completed from all clinical record views. Double-click a clinical item to display details for viewing and editing, depending on what type of clinical item is selected. If the item is a recall you will be prompted to complete the recall.

Tip: To display items that have been logically deleted (flagged as deleted but not removed from the database), right-click in the item list and select Show Deleted Items.

Detail tab actions

For any item listed on the Detail tab you can right-click and take further specific or general actions:
  • Find Associated Service Details - display the service on the Progress Notes tab during which the clinical item was added
  • Show Deleted Items - toggle between displaying deleted clinical items and medications or not. Deleted items are prefixed with <Deleted>.
  • Reset Normal Ordering - revert to default ordering
  • Service List - display a list of all service for the patient
  • For prescribed medications:
    • Stop Medication - stop a medication you want to discontinue
    • Adjust Medication - change the duration, until date and add comments
    • Make Regular - convert a once-off or short course medication to a regular medication
    • Create Once Off Medication Order - create a medication order from a prescription medication for administer or supply
    • Edit Medication - edit a medication created by you in the current service that has not been finalised
    • Repeat Medication (represcribe) - represcribe the selected medication
    • Delete Medication (prescribed in error) - delete a medication that was prescribed in error
    • Finalise Prescriptions - if you have a prescriber number, finalise a prescription to assign a script number
    • Reprint Prescriptions - if you have a prescriber number and you've made changes, reprint a prescription. Ensure you destroy any scripts that you have already printed.
  • Request a Pathology Investigation - open the Add Investigation Request (Pathology) window
  • Request a Diagnostic Imaging Investigation - open the Add Investigation Request (Imaging) window

For conditions, including pregnancy, procedures and history items, to check for any medication interactions, select Check Interactions.

For investigations, you can also print and edit investigation requests, and edit investigation results.

Qualifiers pane

Qualifiers for the record in the main window pane are displayed in a pane of their own at the bottom right. Double-click on a qualifier to display previous measurements.

Changing the order of items

Items in the clinical record can be ordered by other columns such as Description, Comment, and so on by clicking on the title at the top of the column. To restore the default order, right-click a column and select the required option.

Tip: Several of the clinical record views are ordered by a combination of both planned and actual date. These views show the ordering icons in both the planned and actual date columns.