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 iconClinical 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 iconClinical Item Add a clinical item Clinical Records
Medication iconMedication Use to access prescribe, administer, supply or add medication history. Select from the following options.


Medication View

Medications management

Medication iconAdd Medication Use to prescribe medications or create medication orders. Prescribing

Prescribing - Full

Prescribing - Once Off/Short Course

Medication HistoryAdd Medication History Use to add medications prescribed by other services. Medication View Medication History
Administer and SupplyAdminister & Supply Use to administer and supply medication orders. Medications management

Medications Administer

Medications Supply

Administer and SupplyS100 Supply If enabled, use to record supply of S100 medications.
Medication Summary linkMedication Summary Go to the Medication Summary tab. Medication View Medication View
Pathology iconPathology Use to add a pathology request Investigations Investigations
Imaging iconImaging Use to add a diagnostic imaging request Investigations Investigations
Recall iconRecall Add a manual recall
Letter iconLetter Add a new letter
ScanScan Scan a new document Document Scanning Document Scanning
Add attachmentAttachment Add a new Attachment
MessageMessage Add an intramail message
Send SMSSend SMS Send an SMS message
ChangeChange Update item details

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.
BiographicsBiographics View or amend patient details Biographics
ReportsReports Print patient's current service details, summary information or labels Clinical Reporting
ChartsCharts View a list of available charts
AIRAIR 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 buttonServices Display a list of patient's services Service Recording
Claims HistoryClaims 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
MHR record exists MHR no record existsOpen 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 iconTransport Use to manage patient transport requirements

Transport Management

Transport Services

Pause the servicePause Quickly pause the service without displaying customary service exit prompts
Access HelpHelp Open the help
MeHR Connected, MeHR not connected

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 Administration

MeHR e-Registration Auto-Prompt

MeHR to My Health Record Transition

MeHR send profile

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 Administration

MeHR e-Registration Auto-Prompt

MeHR to My Health Record Transition

Consent not asked, Consent given, Consent refused

The patient's current Information Sharing Consent status. Click to change the patient's consent status.

  • Consent not asked - the patient has not been asked for their consent
  • Consent given - the patient has given their consent
  • Consent refused - 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.