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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.
Special Qualifiers
Special qualifiers include calculating qualifiers, HL7 qualifiers, required qualifiers, qualifiers with a range and qualifiers linked to system codes.

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.
    - 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.
      - Body Mass Index
        The Body Mass Index special qualifier calculates BMI to 1 decimal place.
      - Glomerular Filtration Rate
        The special qualifiers GFR (actual body weight) and GFR (ideal body weight) calculate the Glomerular Filtration Rate to 1 decimal place based on the Cockcroft and Gault formula.
      - Required qualifiers
        Some clinical items have required qualifiers that allow multiple providers to contribute to a health assessment over a period of time.
    - 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

Special Qualifiers

Special qualifiers include calculating qualifiers, HL7 qualifiers, required qualifiers, qualifiers with a range and qualifiers linked to system codes.

Calculated Qualifiers

Some qualifiers are calculated automatically, such as BMI and GFR. Other special qualifiers are used in their calculation, such as:

Weight - must be in kg
Height - must be in cm
Creatinine - can be in umol/L or mmol/L

HL7 Qualifiers

Some qualifiers are used to automatically extract values from HL7 format electronic investigation results. Running the report at Report > Reference Tables > Numeric Qualifiers - Central will show you these qualifiers.

Required Qualifiers

When completing a clinical item you may notice some qualifiers have a red or blue dot next to them. A red dot indicates that a value must be entered before the clinical item can be completed. If a required qualifier is not recorded then the item becomes an 'incomplete' item and a recall is created for the item. A blue dot marks a required qualifier that has already been addressed within a specified time interval.

Qualifiers with a range

Some numeric qualifiers have a restriction on the range of values that can be entered. These are particularly useful in cases where different units may be used, such as trying to enter grams instead of kilograms.

System Codes

Some qualifiers are recognised in Communicare reports by a special system code. Running the report at Report > Reference Tables > System Codes and Rule Codes will show you these qualifiers.

14 November 2023