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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.
Clinical Support
Investigations and documents
Communicare receives pathology and imaging results, letters and other documents electronically and sends documents and letters electronically using HL7 messages.
Documents
Documents are the electronic reflection of printed material that is important enough to be recorded in the patient's file. Usually a clinician will want to scan documents into Communicare that cannot be encoded using normal clinical items.
Clinical Document Architecture (CDA)
Communicare can send and receive CDA documents.
Shared Health Summaries
Communicare creates Shared Health Summaries in the CDA format compliant with eHealth standards in Australia. Shared Health Summaries can then be uploaded to My Health Record or an internal CDA repository.
Shared Health Summary Exclusion Statements
Set exclusion statements for any section in the Shared Health Summary that does not include data.

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.
- Medications
  This topic covers all Medications Management functionality within Communicare.
- Clinical Support
  - Investigations and documents
    Communicare receives pathology and imaging results, letters and other documents electronically and sends documents and letters electronically using HL7 messages.
    - Documents and results
      Use the Documents and Results window to display internal, incoming and outgoing documents and incoming results for any patient at your service.
    - Investigations
    - Documents
      Documents are the electronic reflection of printed material that is important enough to be recorded in the patient's file. Usually a clinician will want to scan documents into Communicare that cannot be encoded using normal clinical items.
      - Browsing documents
        Use the Browse Documents window to process scanned documents and manage letters including scanning new documents, writing new letters and viewing, deleting and amending details (but not the scanned image or the date) attached to a document.
      - Scanning documents
        You can scan new documents directly from the main toolbar or from within a Clinical Record.
      - Reviewing documents
        You can review incoming or scanned documents from a patient's clinical record or more generally from Documents and Results.
      - Writing letters and referrals
        You can write letters and referrals from a patient's clinical record. You can also write letters from Documents and Results or from File > Documents.
      - Read-only documents
        Read-only documents in Communicare cannot be modified under any circumstances.
      - Deleting documents
        Use the Browse Documents window to delete documents.
      - Letter viewer
        Use the Letter Viewer to view the contents of a document without printing it.
      - Selecting a template
        Use this window to select a template.
      - Attachments
        You can attach clinical and related documents sourced from email or elsewhere to a patient's clinical record as PDF documents.
      - Sending and Receiving Documents
        Using Communicare you can send and receive documents and results electronically.
      - Clinical Document Architecture (CDA)
        Communicare can send and receive CDA documents.
        Discharge Summaries
        Communicare can create and send Discharge Summaries either in the CDA format (compliant with eHealth standards in Australia) or in a less constrained RTF format. RTF format Discharge Summaries cannot be sent to MeHR, whereas CDA format documents can be sent to either My Health Record or MeHR.
        eReferrals
        Communicare can create and send eReferrals in the CDA format compliant with eHealth standards in Australia.
        Event Summaries
        Communicare creates Event Summaries in the CDA format compliant with eHealth standards in Australia. Event summaries can then be uploaded to My Health Record or an internal CDA repository.
        Shared Health Summaries
        Communicare creates Shared Health Summaries in the CDA format compliant with eHealth standards in Australia. Shared Health Summaries can then be uploaded to My Health Record or an internal CDA repository.
        Shared Health Summary Exclusion Statements
        Set exclusion statements for any section in the Shared Health Summary that does not include data.
        CDA Third Party Storage
        Instead of sending CDA documents like the Event Summary and Shared Health Summary to My Health Record directly, some large health services may use a private repository.
  - Referral Management
    Manage incoming internal and external referrals from a single list.
  - Birth Notifications
    For customers who belong to the Western Australian Country Health Service, use the Birth Notifications module to manage notifications related to births from a single list.
  - Recalls
    Recalls are the elements that make up a care plan. Recalls can be either generated automatically by Communicare or manually created by the user.
  - Datasets
    Datasets are a user-friendly coding system, giving health professionals a standardised way to record data and report on data entered in a patient’s clinical record.

Shared Health Summary Exclusion Statements

Set exclusion statements for any section in the Shared Health Summary that does not include data.

When a user is generating a Shared Health Summary and there is no data in a data section (Medication, Problem/Diagnosis, Procedures and Immunisations) the user must set the exclusion statement for that section. Select from the following options:

None known - use when you want to make a positive statement that there are no known items. This is equivalent to no clinically significant items known. The absence of items in a list is not evidence that there are none known, even if the expectation is that the user will record any existing items in the system. Communicare does not set this exclusion statement if there are no list items, instead it is a positive statement made by a healthcare provider before or during the document authoring process.
None supplied- use when there are no items to list, and the user has not made an explicit statement of None known. None supplied does not imply anything at all about whether there are items, or whether they are known, or why there are no items supplied. Except for shared health summaries, Communicare sets this exclusion statement automatically, in the absence of any list items, and where the user has had the opportunity to specify a different exclusion statement but has not done so.

If the user excludes all clinical information using the tree in the document, it will default to an exclusion statement of None Supplied.

14 November 2023