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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.
Recording antenatal checks
Record antenatal checks by completing a recall or adding an antenatal item to the obstetric 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.
  - 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

Recording antenatal checks

Record antenatal checks by completing a recall or adding an antenatal item to the obstetric record.

If you are creating your own antenatal check, build it using Communicare's qualifiers so that useful summary data can be displayed in the Description of Pregnancy table.

You can complete an antenatal check either from the Progress Notes or Obstetrics tab.

To record an antenatal check:

In the patient's clinical record, either:
- Use the Obstetric tab:
  1. Select Summary > Obstetrics > Current Pregnancy tab.
  2. Select Antenatal Check > Check up;antenatal.
- Use the Progress Notes tab, in the To Do list, double-click <Recall> antenatal checkup and click Complete it.
Enter information for the completed observations.
Click Save.

Each antenatal checkup is displayed in the Description of Pregnancy table on the Current Pregnancy tab. If you want to edit an antenatal check, double-click it in the Description of Pregnancy table.

Change the pregnancy displayed by clicking the Next Pregnancy or Previous Pregnancy arrows on either side of the heading.

If any serious issues arise during antenatal checkups add a Pregnancy Alert. Alerts are not specific to an individual pregnancy: they are saved and will show in subsequent pregnancies. To add an alert, type in the Pregnancy Alert field, or double-click in the field to open a text editor. The Pregnancy Alert label is highlighted red if there is alert information entered.

Add any pregnancy management information to the Pregnancy Management Plan field. Management information is not specific to an individual pregnancy: it is saved and will show in subsequent pregnancies. Double-click in the field to open a text editor where you can provide more information and attach images and so on.

If you need a hardcopy of the antenatal summary, click Letter button Letter and select Antenatal Care Record.

To generate a report of all currently pregnant women for a selected locality group, select Report > Pregnancy > Current Antenatal List. This report is ordered by EDD and indicates gestation and the date of the last antenatal check. You may find women at the top of the list who are more than 50 weeks pregnant, with the label Pregnancy outcome not recorded.

14 November 2023