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.

Every clinical item:
The fields displayed are determined by the Clinical Item Class of the item.
Tip: Information you provide in the Clinical Item is displayed on the Progress Notes tab and is summarised on the Detail tab.

Adding a clinical item

You can use either of the following methods to add a clinical item to a patient's clinical record:
  • Shortcut to a clinical item for commonly used clinical items
  • Clinical items search
Commonly used clinical items are displayed in the shortcut bar at the bottom of all clinical records, grouped by:
  • Calculator - assessment and audit clinical items, for example, for Kessler 10 for mental health assessment or alcohol consumption audit
  • Check up - general items, for example, for Aboriginal and Torres Strait Islander or Women's Health check-ups
  • Child health - items for children's check-ups including birth and age-based development checks
  • Enrolment - items for enrolment in alcohol-related programmes
  • Examination - items for examinations grouped by clinical item topics, for example, cardiovascular or respiratory
  • Group - items for group work, for example, counselling or educational groups
  • HACC/CHSP - items related to HACC or CHSP
  • Immunisation - items for immunisations
  • Referral - clinical items for referrals grouped by specialty, for example, dentist or paediatrician. Specialists should be included in the Address Book and marked for Referrals.
  • STI - clinical items for STI screening or treatment.
To select and complete a commonly used clinical item:
  1. In the shortcut bar, click the required group and select the required clinical item from the list.
    Example shortcut clinical item menu
  2. Complete the required fields.
  3. Click Save.
To search for a clinical item to add to a patient record and complete it:
  1. In the patient's clinical record, click Add a Clinical Item iconClinical Item or press F11.
    Example clinical item search
  2. In the Search-words field, enter a term you would expect to find in the clinical item.
  3. Alternatively, go to the tab that is most likely to show the clinical item you need.
  4. Double-click the clinical item you require.
  5. In the Clinical Item, complete as much information as you want to, including:
    1. In the Comment field, enter any observations.
    2. From the From Date calendar, select when the symptoms are reported to have started.
    3. Set Display on Main Summary if this is a significant, active health event that should be given prominence on the main summary.
    4. If required, set Reason for Encounter to indicate that this is either the main reason for encounter, or if Reason For Visit is also enabled, one of up to four reasons for the patient's visit.
  6. Click Save.

All clinical items

All clinical items include the following fields:
  • Comment - optional free text (or, for Chronic and Acute Medications, the name of the medication). Long comments may be truncated in some reports and grids. Double-click the item to display the full comment.
  • Date/Time - the date and time at which the clinical item actually occurred, which may be Performed Date, From Date, Date referred, Date admitted, and so on. Each clinical item can be configured to be recorded with either a date only or both a date and time by your Communicare Administrator in Clinical Item Type Properties. The default is date only.
  • Display on Summary - this item type should be added to the Clinical Summary. Deselect to remove an item from the clinical summary. This is not visible for the Alert class type.
  • Display on Obstetric Summary - for female patients set 'Display on Obstetric Summary' to add or remove an item from a patient's obstetric summary. This is not visible for the Alert class type.
  • Reason for Encounter - if enabled, set to indicate that this clinical item provides the reason for the encounter and if Reason For Visit is also enabled, one of up to four reasons for the patient's visit. This is not visible for the Alert class type.

Items that were recalls

Clinical items that were recalls include the following fields:
  • Planned Date - the date the Recall clinical item is due
  • Expiry Date - the date the Recall clinical item is due to expire. This is enabled only if your Communicare Administrator has allowed this behaviour for this recall type.
  • Responsibility - the users responsible for completing the recall
  • Cancellation reason - visible if the item is a cancelled recall

Some clinical items

Any clinical item may have supplementary qualifiers. These collect a variety of data in the form of dates, drop-down lists, free text, images, numbers, memos, Yes/No tickboxes and references to another patient.

Numeric qualifiers may have a range of allowed values defined. These values appear in brackets after the units and cannot be exceeded.

Calculated qualifiers are qualifiers that can be calculated from a patient's existing information. A Calculated qualifier will have a Calculate or a Recalculate button underneath the value. Click the button for Communicare to automatically calculate the qualifier's value.

To the right of the qualifiers will be the date and value of the most recent same qualifier type recorded for that patient. There may also be a button to see all previous values of that qualifier type.

Clinical items of a particular class

Other attributes will appear depending on the class of the clinical item. See Clinical Item Attributes.

Clinical items linked to clinical programs

Some clinical items can be used to enrol or exit patients from a clinical program. For example:
  • For drug and alcohol treatment service programs, Alcohol/Other Drug respite enrolment and Alcohol/Other Drug respite exit, Alcohol/Other Drug treatment enrolment and Alcohol/Other Drug treatment exit
  • For Headspace programs, Headspace;Enrolment and Headspace;Closure
  • For home support programs HACC/CHSP Enrolment and HACC/CHSP Exit
  • For integrated team care programs, ITC Enrolment and ITC Exit
  • For primary mental health contacts, PMHC Episode Start and PMHC Episode End
Enrol patients into a clinical program using the enrolment clinical item, then add activity items as required. When the clinical program is complete, to remove the patient from the program, either complete the exit recall or add the matching exit clinical item to the patient's clinical record.
Tip: You cannot add activity items until after a patient has been enrolled in a program. However, you can still add activity items after a patient has been exited from a program. This allows for genuine backdating of clinical items. For example:
  • If you are using an offline client and your clinical program enrolments and exits have got out of step, you can backdate an exit.
  • If items are out of sequence, correct the items.
  • For a patient who exited last week, record an action from two weeks ago.

Generating an e-Referral

If the clinical item currently being added is a Referral, you can generate a CDA e-Referral document for the patient. An e-Referral can be uploaded to the My Health Record or sent via Secure Messaging within the first 8 hours of saving the document.

To generate an e-Referral, click Save & Create eReferral. The clinical item is saved and closed, and an e-Referral is opened.

To learn more about the e-Referral document type, see e-Referrals.

Printing a clinical item

To print a clinical item, click Print & Save. After printing the clinical item, your changes are saved and the item is closed.

Read-only clinical items

Some clinical items may be created and maintained in other systems and integrated into Communicare. These items can be marked as read-only by Customers or Integrators to prevent them from being edited. Read-Only items cannot be edited, deleted, cancelled or completed in Communicare.