Clinical Item Attributes

Clinical items have other attributes determined by their Clinical Item Class.

Admissions

  • Admitted to - the institution the patient was admitted or referred to (see Address Book for information about maintaining this list)
  • Transport mode - the mode of transport used when admitting the patient (see Transport Mode for information about maintaining this list)
  • Alcohol related - the clinical item was caused by or related to alcohol consumption
  • Emergency - An Admission may be marked as an Emergency. Emergency admissions may be considered to be evacuations.

Conditions

  • Episode - defines the episode of care as First, New or Ongoing.
  • Alcohol related - the clinical item was caused or related to alcohol consumption

History

(No additional fields)

Immunisations

  • Actual duration (minutes) - the time spent in minutes performing the clinical item
  • Route and Site - records the route and site of the immunisation
  • Dose (this course) - specify if the immunisation is the first, second, or so on in a course
  • Dose Number - specify the immunisation dose number until now
  • Performed at current encounter place- set if the immunisation was performed at the clinic. If you are recording historical immunisations performed elsewhere in Australia, deselect this option. This field is used for the ACIR (Done Here) report.
  • Administered overseas - if you are recording historical immunisations performed overseas, set instead of Performed at current encounter place.
  • Vaccine batch - record the batch number of the vaccine
  • Serial Number - record the serial number of the vaccine if required. If Serial Number Mandatory is set in the clinical item type properties, you must record the serial number.
  • Vaccine expiry date - record the expiry date of the vaccine

Procedures

  • Actual duration (minutes) - the time spent performing the clinical item in minutes

Referrals

  • The patient is referred - record referrals to another organisation or referrals to this organisation. If the Referral Management module is enabled:
    • This field is disabled and you can create only outgoing referrals
    • Create incoming referrals from the Referrals menu.
  • Organisation - the professional or institution the patient was referred to or from (see Address Book for information about maintaining this list)
  • Provider referred to - free text to record a particular name
  • Appointment Date - record the date and time of an appointment
  • Escort - free text to record the name of an escort for the patient
  • Transport mode - the mode of transport used when the patient is to attend an appointment (see Transport_Mode for where to maintain this list)
  • Referral Complete - the date the referral is deemed to have been completed
  • The referral is Critical - set if the referral is critical for reporting purposes
  • The referral is an Emergency - set to mark the admission as an emergency admission or evacuation
  • The referral is Alcohol related - set to mark the clinical item as caused by or related to alcohol consumption
  • Current Referral status is - a label showing the current status of the referral

Acute Medications and Chronic Medications (Prescribing not enabled)

  • If Prescribing is not used, the Comment field for Acute Medications is labelled Acute medication and the Date is labelled Date prescribed
  • If Prescribing is not used, the Comment field for Chronic Medications is labelled Chronic medication, the Date is labelled From Date, and an End Date field is added

Alert

  • Status - set the alert status to Active, Inactive, Resolved, Entered In Error