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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.
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.
Obstetrics & Pregnancy
Use the Obstetrics tab to view all pregnancies past and present, start and end a pregnancy, and record antenatal checkups.
Recording past pregnancies
You can add past pregnancies that were not recorded in Communicare at the time of pregnancy.

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.
      - Medication Summary
        The Medication Summary displays all active medications, including once-off or regular medications prescribed to the patient, supplied, administered, or added to their medication history.
      - Social & Family History
        Use the Social & Family History tab on the Summary in the clinical record to manage the patient's social and family history.
      - Care Plans
        Use the Care Plan tab on the Summary in the clinical record to manage a patient's care plans.
      - Obstetrics & Pregnancy
        Use the Obstetrics tab to view all pregnancies past and present, start and end a pregnancy, and record antenatal checkups.
        Recording a new pregnancy
        When a woman presents with a confirmed pregnancy, start a new pregnancy.
        Recording past pregnancies
        You can add past pregnancies that were not recorded in Communicare at the time of pregnancy.
        Recording antenatal checks
        Record antenatal checks by completing a recall or adding an antenatal item to the obstetric record.
        Ending a pregnancy
        Record the outcome of a pregnancy in Communicare.
        Gestation calculation
        Current pregnancies recorded in Communicare are displayed in the banner.
    - Progress Notes
      Progress Notes are available for all providers for each 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

Recording past pregnancies

You can add past pregnancies that were not recorded in Communicare at the time of pregnancy.

The Obstetrics tab is available only for patients with a sex of Female.

You can record a past pregnancy in either on the following ways:

Past pregnancy clinical item with details
As a number of pregnancies using gravidity either when adding a new pregnancy or at any time

To record details of a past pregnancy:

In the patient's clinical record, go to the Summary > Obstetrics > Obstetric History tab.
Click Past Pregnancy and select the appropriate clinical item. For example, Delivery;normal vag;liveborn.
In the Pregnancy Number field, enter the correct pregnancy number. Communicare uses the pregnancy number to link pregnancy checks and pregnancy end.
In the Date of delivery field, enter the baby's birth date.
Enter any other information known.
Click Save.

All pregnancy outcomes are listed on the Summary > Obstetrics > Obstetric History tab, in the Previous Obstetric History table.

If you want to edit a pregnancy outcome later, for example, to add the baby's name and sex, double-click it in the Previous Obstetric History table.

Gravidity

You can record past pregnancies simply as a number of gravida, parity, number of miscarriages or number of terminations, in the format Gn Pn Mn Tn without having to record the entire history as individual past pregnancies.

To record past pregnancies as a number:

In the patient's clinical record, go to the Summary > Obstetrics > Current Pregnancy tab.
Click Gravida and select Gravidity.
In the Gravidity window, click in the Parity, Number of miscarriages or Number of terminations and enter the number of pregnancies with each outcome.
To view details of previously recorded pregnancies where available, click Chart.
Click Save.

The number of pregnancies recorded are displayed on the Gravida button.