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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.
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.
Starting a Service
Every time you open a clinical record, a service is started. You have the option of keeping the service or not when you close the clinical record.

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.
    - Recording a Service
      For each patient encounter, record a service.
    - Recording Telehealth Consultations
      Use one of these encounter modes to record telehealth services.
    - Service Selector
      When you open the clinical record for a patient or add a service recording, and a service has already been provided for that patient today, those services are listed in the Service Selector window.
    - Starting a Service
      Every time you open a clinical record, a service is started. You have the option of keeping the service or not when you close the clinical record.
    - Closing a Clinical Record
      To complete a service, close the clinical record.
    - Changing to a Different Service
      If you were part of a past service, you can edit that service.
    - Service Record
      Use the Service Record window to set the provider and encounter place and mode, record billing details and set any requirements.
    - Service Record Filter Selections
      Use the Service Record Filter Selections window to determine which service records are displayed in the Service Recording window.
    - Service Record status
    - Provider Mode Place Selection
      The Provider, Mode and Place and Program window is displayed when you open a clinical record and Communicare is unable to identify the provider and mode-place for opening the clinical record.
    - Preselecting the Provider
      You can set the Provider, Encounter Place, Encounter Mode and optional Program used for all future services.
    - Medicare Assignment Form
      You can print patient and service details to a Medicare form ready for signing.
  - 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.
- Medications
  This topic covers all Medications Management functionality within Communicare.
- Clinical Support

Starting a Service

Every time you open a clinical record, a service is started. You have the option of keeping the service or not when you close the clinical record.

To capture statistics for OATSIH Service Activity Reporting, Communicare does not allow anything to be recorded or edited on a person's clinical record until you have defined the service, that is, who provided the service and what date the service was provided.

To define a new service, open a clinical record, either directly or in Service Recording.

Starting a service from Service Recording

To start a service from Service Recording:

In the main toolbar, click Service Recording.
In the list, double-click a patient who is already queued and click Open Clinical Record.
If the patient has a status of Waiting, click Yes to confirm that you want to see the patient now.

If the patient is not already listed, first add them:

In the main toolbar, click Service Recording.
Click Add and select a patient.
Select a session.
Select a provider, place, mode details (if not already defined - see Preselecting the Provider) and date and click Save.
Double-click the patient and click Open Clinical Record.

The service is started and you can record clinical items.

Starting a service from the Clinical Record

Open a Clinical Record to automatically start a service for today using the provider, place and mode already selected. If you do not have these details preselected you will see a form requesting these details (see Provider\, Mode\, Place Selection).

To start a service from the Clinical Record, on the main toolbar, click Clinical Record and select the patient.

Editing a service

When revisiting a clinical record on a particular day, do not start a new service unless the patient has left and returned for a different reason. You should normally select the existing service.

To add more details to an existing service (for example, to complete progress notes at the end of the day or record a home visit):

In the Service Recording window, double-click the required patient.
Click Open Clinical Record.
In the Select Service window, select the required service and click Yes - Open selected service.
On the Progress Notes tab, today's services are listed on the service pane on the right.
Double-click the item you want to edit, update it and click Save.
Close the service.
Select the required Medicare option.

14 November 2023