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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.
Care Plans
Use the Care Plan tab on the Summary in the clinical record to manage a patient's care plans.

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.
    - 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 items
      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
      Special qualifiers include calculating qualifiers, HL7 qualifiers, required qualifiers, qualifiers with a range and qualifiers linked to system codes.
    - Referral Status
      A referral might have one of these statuses.
    - Finding Hidden Windows
    - Data Entry Wizard
- Medications
  This topic covers all Medications Management functionality within Communicare.
- Clinical Support

Care Plans

Use the Care Plan tab on the Summary in the clinical record to manage a patient's care plans.

Before you can add a care plan for a patient, the care plan template must be added to Communicare and assigned the Document type of Care plan template and a viewing right. Care plans are displayed on both the Care Plan tab and on the Detail tab under the class of Documents. For more information, see Communicare Templates.

To view care plans, you must belong to a user group with the same viewing right as that assigned to the care plan template, typically Care Plan.

The icon for the Care Plan tab changes according to the content.

- displayed when there are no active care plans
- displayed if there are one or more active care plans and you have the correct viewing rights to see the care plan

To add a new care plan for a patient:

In the patient's clinical record, on the Summary > Care Plantab, click New Care Plan.
In the Select Document Template window, select the required care plan and click Select.
Tip: Each patient can have only one care plan for each topic.
A blank care plan opens in the Letter Writer.
Complete the care plan as required.
Click Close and in the Save window, click Yes.
Click Save.

The care plan is saved in the user's clinical record and displayed on the Care Plan tab.

If you need to print the care plan, on the Care Plan tab, click Print icon Print/Preview Current Care Plan.

If you need to update a care plan, click Revise care plan icon Revise Care Plan and repeat steps 3-5 above.

If the selected care plan is no longer required or valid, to archive the care plan, click Archive care plan icon Archive Care Plan. The archived care plan document is available on the Detail tab.

Multiple care plans

If you have multiple care plan templates that belong to separate default topics, you can add more than one care plan, as long as each care plan uses a template with a different default topic. For example, a patient can have two care plans, one that belongs to the General & Unspecified default topic and the other that belongs to the Psychological default topic.

If a patient has multiple care plans, on the Care Plan tab, Multiple is displayed beside the topic.
Multiple care plans in a clinical record

Multiple care plans in a clinical record

To display the required care plan, select the topic to which it belongs from the Care Plan list.

14 November 2023