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Encounters
Open a service recording for patient interactions and add clinical items, record progress notes, prescribe medications, review investigations, write referrals and manage recalls.
Encounters
Record patient encounters in Communicare using any one of the following methods.
Clinical Records
The clinical record comprises all clinical information recorded for a patient in Communicare by your health service. It includes clinical items and recalls.
Progress Notes
Progress Notes are available for all providers for each service.
Reasons For Visit

Encounters
Open a service recording for patient interactions and add clinical items, record progress notes, prescribe medications, review investigations, write referrals and manage recalls.
- Encounters
  Record patient encounters in Communicare using any one of the following methods.
  - Service Recording
    In Communicare, a service is where a patient interacts with a service provider. In general, it means to have a consultation with a health care provider, that is, a Doctor, Nurse, or Healthworker.
  - Clinical Records
    The clinical record comprises all clinical information recorded for a patient in Communicare by your health service. It includes clinical items and recalls.
    - Action Required Banner
    - Summary tab
      The summary tab contains a summary of the patient's clinical record. Which panes are visible depends on which System Parameters have been set.
    - Progress Notes
      Progress Notes are available for all providers for each service.
      - Reasons For Visit
      - Changing a Progress Note
      - Text Shortcuts
        Use text shortcuts to improve efficiency when writing progress notes or letters for commonly used blocks of text.
      - View Progress Notes for Service
    - 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.
    - Clinical Item Maintenance
      A Clinical Item is the basic element of a Clinical record. Clinical items are included in Communicare by default, but can be customised for your health service.
    - Clinical Terms Browser
      The Clinical Terms Browser is displayed each time you need to select a Clinical Item Type.
    - Episode
    - Qualifier edit panes
      In the clinical item, set or change the values of qualifiers associated with that clinical item in the qualifier edit panes.
    - Add drawings to clinical items
      Use drawing qualifiers in clinical items to more accurately display conditions or procedures on preset clinical images.
    - Special Qualifiers
      Some qualifiers are special.
    - Referral Status
      A referral might have one of these statuses.
    - Finding Hidden Windows
    - Data Entry Wizard
  - Clinic Attendance
    Use the Clinic Attendance module to record the numbers of consultations or encounters between a patient and doctor or other service provider, using predefined age and sex categories.
- Medications
  This topic covers all Medications Management functionality within Communicare.
- Clinical Support

Reasons For Visit

If required, for each encounter, you can specify up to four reasons for a patient's visit to your health service.

Limitations

The Reason For Visit Clinical Record Feature must be enabled. See System Parameters - Clinical for more information.

If you want to be able to add clinical items to the 'Reasons For Visit' list automatically, the Reason For Encounter Clinical Item Attribute must also be enabled. System Parameters - Clinical

Adding reasons for visit

You can add reasons for a patient's visit either automatically from the clinical item, or manually in the progress notes.

To add a reason for a patient's visit automatically:

In the patient's clinical record, click Clinical Item.
In the Clinical Terms Browser, select the required item.
In the Add Clinical Item window, set Reason For Encounter.
Click Save.

At the end of a consultation, to specify a reason for the patient's visit manually in their Clinical Record:

On the Progress Notes tab, in the Reasons for Visit section, click Manage Reasons.
In the Reasons for Visit window, click Select and from the Reason 1 list, select the primary reason for the patient's visit. Both the clinical items that have been previously applied to this patient, and all items in the Reasons for Visit lookup table are included in the list.
Alternatively, in the Reason 1 field enter a reason.
If required, repeat steps 2 or 3 in the other Reason fields, adding up to 4 reasons.
Click OK.

Results

The selected reasons are displayed on the 'Progress Notes' tab.

Example Reasons for visit

In the Progress Notes, if you delete a clinical item for which you set Reason for Encounter, it is also removed from the Reasons For Visit list.