Clinical Records

The Clinical Record module comprises all Clinical Item and Recall recording. It is a core element of the Communicare system.

To access clinical records, click Clinical Record icon Clinical Record or select Patient > Clinical Record.

The Clinical Record has three main tabs which display the summary, the progress notes and the details of a patient's record.

Common toolbar

The buttons described in the following table are visible regardless of which tab is selected.

Table 1. Main Toolbar
Button	Secondary Link	Description	Module	User Group System Rights required
Clinical Item		Add a clinical item		Clinical Records
Medication		Use to access prescribe, administer, supply or add medication history. Select from the following options.	Prescribing Medication View Medications management
	Add Medication	Use to prescribe medications or create medication orders.	Prescribing	Prescribing - Full Prescribing - Once Off/Short Course
	Add Medication History	Use to add medications prescribed by other services.	Medication View	Medication History
	Administer & Supply	Use to administer and supply medication orders.	Medications management	Medications Administer Medications Supply
	S100 Supply	If enabled, use to record supply of S100 medications.
	Medication Summary	Go to the Medication Summary tab.	Medication View	Medication View
Pathology		Use to add a pathology request	Investigations	Investigations
Imaging		Use to add a diagnostic imaging request	Investigations	Investigations
Recall		Add a manual recall
Letter		Add a new letter
Scan		Scan a new document	Document Scanning	Document Scanning
Attachment		Add a new Attachment
Message		Add an intramail message
Send SMS		Send an SMS message
Change		Update item details
Remove		For security, Communicare requires a reason to remove many items from a patient's Clinical Record and keeps a database record that can be retrieved if required (right-click and select Show Deleted Items). This is called logical deletion. Selected items are deleted in one of a number of ways: Normally the item will be permanently deleted after a warning is shown. This applies to Procedures, Conditions, Immunisations, Adverse Reactions, Referrals, Admissions, History. These items will not be revealed when you select Show Deleted Items. For items in the Clinical Items summary, this action removes only the summary, not the item. For prescriptions, the deletion is logical For a regular medication on the summary page, the action removes that medication from the regular list. To return the item, right-click the medication and select Make Regular. For investigation results, a matched and reviewed result cannot be deleted. If the result is not matched to a request, it can be logically deleted: this action unmatches the result from the patient. To undelete this result, go to the Review Results window on the main toolbar and match this result to the patient again. For the patient's documents and care plans, the deletion is logical. For Administer and Supply, the deletion is logical. Tip: To display deleted medications and other items, in the clinical record, on the Detail tab, right-click and select Show Deleted Items.
Biographics		View or amend patient details	Biographics
Reports		Print patient's current service details, summary information or labels	Clinical Reporting
Charts		View a list of available charts
AIR		Check the patient's immunisation history with AIR. If the system is configured to have multiple customised URL links, in the Clinical record the AIR button is replaced with a Go To button and the list of URL links are displayed in a menu.
Services		Display a list of patient's services	Service Recording
Claims		View all Medicare items previously selected for claiming for the patient, including all items marked for claiming, whether or not they have been submitted, processed or paid
Open My Health Record		Access a patient's My Health Record profile. The button background is red if the patient does not have an existing My Health Record, or green if the patient does have an existing My Health Record. If MeHR to My Health Record Transition is enabled, you can also use this option to access a patient's MeHR profile.	My Health Record Access My Health Record Assisted Registration MeHR to My Health Record Transition	My Health Record Access My Health Record Assisted Registration
Transport		Use to manage patient transport requirements	Transport Management Transport Services
Pause		Quickly pause the service without displaying customary service exit prompts
Help		Open the help
,		Access a patient's MeHR profile. The button background is red if the patient does not have an existing MeHR, or green if the patient does have an existing MeHR. If MeHR to My Health Record Transition is enabled, this option is available only if the following conditions are true: Patient has a MeHR Patient does not have a My Health Record Provider has MeHR access Provider does not have My Health Record access	MeHR MeHR Administration MeHR e-Registration Auto-Prompt MeHR to My Health Record Transition
		Send a health profile to MeHR. If MeHR to My Health Record Transition is enabled, this option is available only if the patient does not have a My Health Record and the provider does not have access to the My Health Record.	MeHR MeHR Administration MeHR e-Registration Auto-Prompt MeHR to My Health Record Transition
, ,		The patient's current Information Sharing Consent status. Click to change the patient's consent status. - the patient has not been asked for their consent - the patient has given their consent - the patient has refused to share their data across multiple organisations. This button is available only if more than one organisation exists in Organisation Maintenance.	Information Sharing Consent Maintenance Information Sharing Consent Recording
Health Care Home (HCH)		The patient HCH Tier details are displayed next to the patient banner only if the patient is registered for HCH and the HCH Tier is recorded.

Finding out more detail about an item

For any item in the clinical record right-click and select Find Associated Service Details. Communicare will take you to the service details for that item, by highlighting the progress notes that belong with that item on the Progress Notes tab. To display further details about a progress note, double-click it.

Commonly used clinical items

At the bottom of the clinical record are buttons which, when clicked, display a menu of commonly used items.

These menu buttons can be configured at your site to reflect your own needs. Your Communicare Administrator can define buttons by creating a keyword of $Button Name and attaching this keyword to the appropriate items (see Clinical Item Keyword). The items are listed alphabetically.