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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.
Obstetrics & Pregnancy
Use the Obstetrics tab to view all pregnancies past and present, start and end a pregnancy, and record antenatal checkups.

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.
      - 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

Obstetrics & Pregnancy

Use the Obstetrics tab to view all pregnancies past and present, start and end a pregnancy, and record antenatal checkups.

Only users who have the Maternal & Sexual Health viewing right will see the details on the Obstetrics tabs.

The antenatal record records the pregnancy number for all ICPC-2 PLUS clinical items that record either a pregnancy start, pregnancy check or pregnancy end.

Your Administrator can customise Communicare pregnancy items:

Use your own antenatal check by attaching the System Code of PRE and the Rule Code of PR-CHECK to an item
Disable any of the pregnancy end items provided by ICPC-2 PLUS that are not required

All Obstetrics tabs

All Obstetrics tabs display the following information:

Description of Pregnancy - lists information from each antenatal check. To view information from previous pregnancies where relevant, click Next Pregnancy or Previous Pregnancy arrows on either side of the heading.
Relevant Medical History - displays any important clinical items that relate to obstetrics for which Display on Obstetric Summary has been set. To remove an item from the list, deselect Display on Obstetric Summary in the clinical item or right-click the item in the list and select Remove Item from Obstetric Summary.
Set the default value of Display on Obstetric Summary in the clinical item type in the Clinical Item Type Reference Table.

Deleting Pregnancy Start and Pregnancy End items recorded by mistake

If you accidentally record an incorrect new pregnancy, end pregnancy or past pregnancy item, delete the item from the Detail tab or the Progress Notes tab.

In the Obstetrics tab, you can double-click an item to edit it, but you cannot delete it.

14 November 2023