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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.
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.
Social & Family History
Use the Social & Family History tab on the Summary in the clinical record to manage the patient's social and family history.

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.
      - Medication Summary
        The Medication Summary displays all active medications, including once-off or regular medications prescribed to the patient, supplied, administered, or added to their medication history.
      - Social & Family History
        Use the Social & Family History tab on the Summary in the clinical record to manage the patient's social and family history.
      - Care Plans
        Use the Care Plan tab on the Summary in the clinical record to manage a patient's care plans.
      - Obstetrics & Pregnancy
        Use the Obstetrics tab to view all pregnancies past and present, start and end a pregnancy, and record antenatal checkups.
    - Progress Notes
      Progress Notes are available for all providers for each 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

Social & Family History

Use the Social & Family History tab on the Summary in the clinical record to manage the patient's social and family history.

Any information added to the Social & Family History clinical item type is summarised on the Social & Family History tab.

You can provide updates in the Social & Family History clinical item to the Social history or Relevant family history qualifiers or directly in the Social & Family History tab. All updates are displayed in both the tab and the Social & Family History clinical item. If a Social & Family History clinical item doesn't already exist for the patient, it is added.

Tip: To refresh the information displayed on the tab, change to another tab and back again.

Note: When the clinical item is created, it uses the current date instead of the date of the service. This means that even if the date of the service is changed to a past date when updating the history, Communicare creates a clinical item with today's date.

14 November 2023