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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.
Progress Notes
Progress Notes are available for all providers for each service.
Reasons For Visit
Your health service may require you to record one or more reasons for a patient's visit in their clinical record. The reason for the patient's visit may be added manually or automatically.

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.
    - Progress Notes
      Progress Notes are available for all providers for each service.
      - Reasons For Visit
        Your health service may require you to record one or more reasons for a patient's visit in their clinical record. The reason for the patient's visit may be added manually or automatically.
      - Changing a Progress Note
      - Text Shortcuts
        Use text shortcuts to improve efficiency when writing progress notes or letters for commonly used blocks of text.
      - View Progress Notes for 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

Reasons For Visit

Your health service may require you to record one or more reasons for a patient's visit in their clinical record. The reason for the patient's visit may be added manually or automatically.

To enable reasons for a patient's visit to be added manually in progress notes, Reason For Visit must be set in System Parameters - Clinical.

To enable reasons for a patient's visit to be added to the Reason For Visit list automatically from clinical items, Reason For Encounter must also be set in System Parameters - Clinical.

If required, for each encounter, you can specify up to four reasons for a patient's visit to your health service.

You can add reasons for a patient's visit either automatically from the clinical item, or manually in the progress notes.

To add a reason for a patient's visit automatically from a clinical item:

In the patient's clinical record, click Clinical Item.
In the Clinical Terms Browser, select the required item.
In the Add Clinical Item window, set Reason For Encounter.
Click Save.

The selected reasons are displayed on the Progress Notes tab.
Example Reasons for visit

Example Reasons for visit

In the Progress Notes, if you delete a clinical item for which you set Reason for Encounter, it is also removed from the Reasons For Visit list.

At the end of a consultation, to specify a reason for the patient's visit manually in their clinical record:

On the Progress Notes tab, in the Reasons for Visit section, click Manage Reasons.
In the Reasons for Visit window, click Select and from the Reason 1 list, select the primary reason for the patient's visit. Both the clinical items that have been previously applied to this patient, and all items in the Reasons for Visit lookup table are included in the list.
Alternatively, in the Reason 1 field enter a reason.
If required, repeat steps 2 or 3 in the other Reason fields, adding up to 4 reasons.
Click OK.

14 November 2023