Home
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.
Changing a Progress Note

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

Changing a Progress Note

When viewing or changing Progress Notes in Communicare, there are some restrictions for security reasons. These restrictions are implemented based on the Communicare logon username.

Auditing

All progress notes display the Username of the User who created or modified that progress note. Where a progress note was amended after the original service, it will display '\<Amended\>' in the contact header in the progress note history. With detail level 5, any previous versions will also be available for viewing in the progress note history, and are shown in grey with '\<Deleted\>' in the contact header.

Viewing Progress Notes

Users who do not have any viewing rights cannot see progress notes.
Users who do not have the viewing right attached to a progress note cannot see that progress note.

Changing Progress Notes

Users who do not have any viewing rights cannot change or write any progress notes.
Progress notes can only be written if you log on to Communicare with the Username that identifies the Provider. Anyone can write or change a Progress Note on behalf of a provider who does not have a LOGON Username.
If a provider has a DELEGATED user then the delegated user can also write or change the progress notes for that provider.
Only the progress notes for the current consultation can be changed. In order to change other progress notes you will have to first select the correct consultation. See Progress Notes for help on how to do this.

Specifying the Username and Delegated User for a Provider

This is done at File > Reference Tables > Provider. If electronic claiming is enabled then only the Administrator or the Provider can change these details.

15 November 2023