Clinical Item Classes

A clinical item class is a grouping of clinical item types that have common properties and attributes (data values).

These common properties include a description, comment and date. All are linked to a patient and a service provider with the exception of incoming, unmatched or unreviewed documents, and results and automated recalls not yet edited by a service provider.

Clinical item classes are system defined. Some classes are only available if specific modules are enabled in the System Parameters window.

Communicare records the following classes of clinical items.

Classes used for local clinical items

The following classes can be used for clinical items:
  • Admission - use to record admissions elsewhere. Record the place admitted using the Address Book to find entries flagged as Admission Place.
  • Condition - use to record symptoms, complaints, infections, neoplasms, injuries, congenital anomalies and other diagnoses.
  • History - use to record items such as 'history of [condition]' and 'family history of [condition]' rather than actual diagnoses for the patient or family members.
  • Immunisation - use to record actual immunisations and vaccinations, whether performed by the provider or performed elsewhere. Use to record batch numbers, expiry dates, route and site, serial numbers and so on. Immunisations are recallable. Recalls for immunisations can be cancelled.
  • Procedure - use to record any activity performed on or for the patient. This may include clinical procedures, examinations and health checks, but also such activities as 'advice and education' and program-specific activity, such as HACC activities. Procedures are recallable. Recalls for procedures can be cancelled.
  • Referral - use to record formal referrals both outgoing and incoming. Referral can also be configured to manage incoming referrals. Record the referral source or destination using the Address Book to find entries flagged as Referral Place. Other attributes include appointment dates (for external agencies) and a date the referral was deemed to be complete. Referrals are recallable. Both recalls for and initiated but not yet complete referrals can be cancelled.
  • Alert - use to record structured and codified alerts about a patient that staff of the health service need to know. The status of the Alert can be any of the following:
    • Active - the alert is current and requires consideration by the health service
    • Inactive - the alert is no longer current but may have an impact on future encounters
    • Resolved - the alert is closed and no longer requires consideration by the health service
    • Entered In Error - the alert was documented in error, either because the history was reported incorrectly or it was entered in error
The following classes may be used, but should not be used if the Prescribing module is enabled:
  • Acute medication - used when Prescribing is not used, to document giving medication for acute conditions
  • Chronic medication - used when Prescribing is not used, to document giving medication for chronic conditions

Classes not used for local clinical items

The following single central items have a specific purpose and cannot be used for local clinical items:
  • Ix Result - Investigation Result used to link to incoming pathology and radiology results
  • Ix Request - Investigation Request used to link to outgoing pathology and radiology requests recorded formally in Communicare
  • SMS - SMS Message used to record SMS messages formally in Communicare
  • Adverse reaction - Adverse Reaction, used to link to adverse reactions recorded formally in Communicare.

Classes that are not actual clinical items

The following classes are used to record information in the database:
  • Prescription - prescriptions are recorded in the database with this class
  • Supply - formal supplies are recorded in the database with this class
  • Administer - formal administering are recorded in the database with this class
  • Document - documents created in or imported into Communicare are recorded in the database with this class, including scanned documents, incoming and outgoing letters, uploads and downloads to My Health Record, and so on
  • Email - formal intramail messages are recorded in the database with this class

The classes Prescription, Supply and Administer are prefixed with Rx -.