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.

If a document can be encoded or recorded as a normal clinical item it does not need to be recorded as a document. Clinical items are structured so that relevant health information can be extracted by using reports, whereas documents cannot be analysed with any reliability by any method.

When should I use documents?

Limit the use of documents to those cases where the information does not need to be encoded into clinical items and clinical details are not required. Documents are useful for logging actions that have been performed. It can be useful, for example, to store a scanned document from a faxed or emailed discharge summary.

If there is a need to send a letter it is useful to have it recorded just as a history log. Documents written in Communicare can then be sent using secure email. Referral letters should be created from a referral clinical item so that follow-up can be monitored. The referral letter itself is a record of what was written but the clinical item is a record that a referral has been initiated.

Scanned documents and electronic documents

Scanned documents are those documents that are directly scanned into Communicare. All other documents are Eelectronic documents.

Documents and access rights

All documents are subject to Viewing Rights. This means that if a document is marked as highly sensitive and you do not have the right to see highly sensitive data you will not be able to see the document. However, all documents with no viewing right assigned (except incoming electronic documents) will be visible to all users.

Documents will always be visible to users inside the clinical record if the users have the appropriate level of security access to see them.

Note: Documents such as letters created with no viewing right are visible only to users who belong to a user group that has the Electronic Documents system right enabled. Incoming documents do not have a viewing right until one is assigned and are not visible to users unless they belong to a user group with the Electronic Documents system right. This approach prevents potentially sensitive information being visible to everyone.

Documents and system rights

System rights assign the security access level for using Communicare modules. There are two system rights in Communicare that deal with Documents:

Document Scanning - users can scan documents into Communicare from the Documents and Results window and from within the clinical record.
Electronic Documents - users can create any outgoing document from the Documents and Results window. All users can create outgoing documents from within the clinical record. This system right also allows users to see incoming documents that do not have an access right assigned. This means only users with the Electronic Documents system right can see the incoming documents as they arrive. After incoming documents have been reviewed, they are visible according to their newly assigned viewing right.

Table 1. Summary of document access
Document type	With Viewing Right	Without Viewing Right
Scanned document	Visible only to those with that viewing right	Visible only to those with `Electronic Documents` system right
Incoming document	Visible only to those with that viewing right	Visible only to those with `Electronic Documents` system right
Other documents (letters created in Communicare)	Visible only to those with that viewing right	Visible only to those with `Electronic Documents` system right