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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.
Obstetrics & Pregnancy
Use the Obstetrics tab to view all pregnancies past and present, start and end a pregnancy, and record antenatal checkups.
Gestation calculation
Current pregnancies recorded in Communicare are displayed in the banner.

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.
        Recording a new pregnancy
        When a woman presents with a confirmed pregnancy, start a new pregnancy.
        Recording past pregnancies
        You can add past pregnancies that were not recorded in Communicare at the time of pregnancy.
        Recording antenatal checks
        Record antenatal checks by completing a recall or adding an antenatal item to the obstetric record.
        Ending a pregnancy
        Record the outcome of a pregnancy in Communicare.
        Gestation calculation
        Current pregnancies recorded in Communicare are displayed in the banner.
    - 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

Gestation calculation

Current pregnancies recorded in Communicare are displayed in the banner.

Pregnancy in the banner

The pregnancy label in the banner may show any of the following:

If the gestation can be calculated and is less than 50 weeks, the label reads Pregnant (n/40) + days, where n is the current gestation in weeks.
If the gestation can be calculated and is 50 weeks or more, the label reads Pregnancy outcome not recorded
If the gestation cannot be calculated, the label reads Pregnant (gestation unknown).

The gestation shown in the banner is calculated in the following way:

If an Estimated delivery (by date) is recorded for the current pregnancy, this is used to calculate the gestation based on today's date
If there is no Estimated delivery (by date) recorded for the current pregnancy, the Estimated delivery (by ultrasound) is used to calculate gestation based on today's date
If no estimated delivery date is recorded for the current pregnancy, the latest Gestation is used based on the date the latest gestation was recorded and today's date
If no estimated date and no gestation is recorded for the current pregnancy, the Date of LNMP is used based on today's date

This means that the latest recorded Estimated date of delivery (by date) is in fact the current 'best guess'. For this reason, if a recent ultrasound is deemed to be more accurate that the latest Estimated date of delivery (by date), the latter should be updated with the recent ultrasound estimate.

14 November 2023