Clinical Record Reports

Table 1. Clinical record reports
Report > Clinical Record	Description
Adverse Reactions Audit	Shows all patients who have some form of Adverse Reaction recorded. Display all patients with alert data or only those with alerts containing the keywords 'adverse', 'reaction', 'allergy', 'allergic', 'sensitivity', 'intolerance', 'intolerant', 'nkda' or 'nka' and details of the alert. You can also show all patients or only those without a formally recorded adverse reaction. Use this data to assist in transcribing reactions into the new Adverse Reaction feature. Alerts and ICPC Adverse Effect codes should be discontinued, and all adverse reactions in the future should be recorded using the new feature. This will allow users to be warned of reactions when prescribing medication. Administrators should run this report. Users without the system right of Clinical Record will not be able to see any of the alert data.
Adverse Reactions New and Modified	Identify records where an adverse reaction has been added or modified within a date range. Use the report to monitor record accuracy as well as to the identify cases requiring notification to the Australian Adverse Drug Reaction Reporting System.
Alcohol Related Items	Shows all clinical items recorded as alcohol-related between two dates. Fictitious patients are excluded. Before providers can capture this information, Alcohol must be set on the File > System Parameters > Clinical tab.
Alert Analysis	Analyses patients by status and counts those with something recorded in the alert of the clinical record or any adverse reactions and those with nothing. Details are broken down into those with free text alerts, those with no known allergies, those with drug allergies and those with non-drug allergies. Use this report to analyse compliance with recording of patient drug allergies and other important information.
Conditions and Qualifiers Analysis	Lists all patients who satisfy the biographic criteria with the latest value and date for up to four numeric qualifiers and one non-numeric qualifier. It also lists the latest diagnosis for each patient that belongs to a specified clinical item group. An additional filter allows you to show either all patients (with any item in the clinical item group selected) or only those patients who have an item in the clinical item group selected. For example, you may choose to select the weight, BMI, HbA1c and cholesterol for women aged over 40 and show the latest diagnosis of diabetes. This will allow you to monitor progress of known diabetic patients and also examine qualifiers for patients without such a diagnosis to identify patients that should be recalled for a consultation. For those qualifiers not required, select `(N/A)`. Similarly, if you do not need to examine a clinical item group, select `(N/A)`.
Infections Between Two Dates	Shows all recorded infections between two dates grouped by topic and infection.
INR Chart	Prints the current (latest) Target INR (International Normalised Ratio) value and date and displays a table containing historical dates with INR values and warfarin dosage with the associated clinical item comment. For more information, see INR Chart.
Kidney Disease Outcomes	Shows the most recent GFR for any current patient whose most recent ACR was > 3.4 mg/mmol. GFR is recorded in mL/min. Also included are any patients with a diagnosis from the URINARY DISEASE, OTHER group. The results are grouped into appropriate categories to indicate the level of Chronic Kidney Disease. Definitions are from the Kidney Disease Outcomes Quality Initiative. Also included is a record of patients who are currently or regularly being prescribed an ACE inhibitor or ARB. Also shown is the most recent diagnosis from the URINARY DISEASE, OTHER group. This can be used to see if a patient's most recent diagnosis is consistent with the latest pathology results. The report uses the Communicare Central qualifiers of 'ACR (Alb/Creat Ratio)' and 'GFR (ideal body weight)' or 'GFR (actual body weight)' or 'eGFR (Estimated GFR)'. Note: These results are intended as a guide to patient management only. Care should be taken when interpreting these results.
No Formal Allergy Status Recorded	Lists the patients whio do not have any formal Adverse Reaction Status recorded. The report does not check the "Alerts and Other Information" section. Export this report to include patient address and phone numbers.
NT Renal Care Summary Report HRN	Report for the NT DHF Renal Care Coordinator showing all patients with a latest GFR less than 60 broken down into each stage of renal failure. The latest GFR and creatinine values are shown. When exporting to Excel there are additional data for the most recent ACR, BP, potassium, LDL, smoking status, Hb and HbA1c. It is similar to the Kidney Disease Outcomes report, except it is based only on GFR values and does not consider ACRs or diagnoses.
Patients with Dx but no Item	Lists all patients who have a clinical item within a selected clinical item group who do not have a specific completed clinical item type or vice versa. This is a patient-based report. It will list patients once only, regardless of the number of times group clinical items have been recorded for the patient. Use this report to locate all patients belonging to a particular disease or other group who do not have a specific completed clinical item or for patients with the completed clinical item but no specific diagnosis or other clinical item (e.g. look for patients with diabetes, non-insulin dependent who do not have a completed Cycle of care;annual;diabetes).
Patients with Dx but no Qualifier	Lists all patients who have a clinical item within a selected clinical item group who do not have a specific numeric qualifier within a specified range or vice versa (only the latest qualifier for a patient is considered). This is a patient-based report. It will list patients once only, regardless of the number of times group clinical items have been recorded for the patient. Use this report to locate all patients belonging to a particular disease or other group who do not have a specific qualifier of a specific value or for patients with the qualifier but no specific diagnosis or other clinical item (e.g. look for patients with diabetes, non-insulin dependent who have a BMI greater than 30).
Patients with Dx but no Recall	Lists all patients who have a clinical item within a selected clinical item group who do not have a recall for a selected procedure or vice versa. This is a patient-based report. It will list patients once only, regardless of the number of times group clinical items have been recorded for the patient. Use this report to locate all patients belonging to a particular disease or other group who do not have a recall for a recommended periodic procedure or for patients with a recall for a procedure but no specific diagnosis or other clinical item (e.g. look for patients with diabetes, non-insulin dependent who do not have a recall for Cycle of care;annual;diabetes).
Procedures and Referrals by Provider	For the selected date range, for each provider, lists: Provider name Place mode where the procedures/referrals were done Name of the procedure/referral Number of times the procedure/referral was done Providers who have performed no procedures during the selected period are not listed on the report. Fictitious patient procedures are excluded. Use this report to gain an appreciation of the data recording and clinical service activity of each provider.
Qualifier Analysis for Selected Provider	Shows counts of the qualifier usage of all clinical items recorded by a specified provider for a specific clinical item or class, including averages, maxima and minima for numeric qualifiers and individual counts of each reference type qualifier response. Numeric qualifiers are also summed for a grand total - this is not a sensible value for, say, HbA1c and should be ignored, but is valuable for numeric qualifiers such as 'Amount spent in dollars', and so on. Use this report to analyse responses to the qualifiers of particular items that belong together. It can also be used to summarise and monitor details that are recorded by a specific provider.
Selected Clinical Item Group Analysis	Counts all clinical items recorded between two dates where the clinical item belongs to a selected clinical item group. The report excludes fictitious patients but includes deceased patients. Filter by patient's locality or locality group where they were living at the time of the diagnosis. Partially complete procedures, that is, those with required qualifiers that have not been completed, are included in this report. For each item in the selected clinical item group, the report lists: Clinical Item Type Locality of the client's home Count of the clinical item for clients living at that locality Total count of the clinical item for all localities Recording provider Use this report to report on outbreaks of particular groups of disease, or to count particular types of procedures performed.
Selected Clinical Item Group	Lists all clinical items recorded between two dates where the clinical item belongs to a selected clinical item group. The report excludes fictitious patients but includes deceased patients. Partially complete procedures, that is, those with required qualifiers that have not been completed, are included in this report. Use this report to report on outbreaks of particular groups of disease for all localities.
Social and Family History Analysis	Analyses patients by status and counts those with something recorded in the social or family history of the clinical record and those with nothing. Use this report to analyse compliance with recording of social and family history.
Social and Family History Patients	Analyses patients by status and indicates those with something recorded in the social or family history of the clinical record and those with nothing. Use this report in conjunction with the Social and Family History Analysis report.
Unconfirmed Diagnoses	Lists all patients who have a condition within a selected clinical item group where the comment contains a question mark (?). Use this report to locate all patients belonging to a particular disease or other group whose condition may still need confirmation. Where the condition is confirmed, the clinical item should be edited to remove the question mark. Where the condition is not confirmed, the item should be deleted (note that the original progress note will contain evidence of the initial suspicions). Unconfirmed diagnoses in Communicare are considered for reporting purposes and for calculations such as cardiovascular risk.

Adverse Reactions Audit

Shows all patients who have some form of Adverse Reaction recorded.

Display all patients with alert data or only those with alerts containing the keywords 'adverse', 'reaction', 'allergy', 'allergic', 'sensitivity', 'intolerance', 'intolerant', 'nkda' or 'nka' and details of the alert. You can also show all patients or only those without a formally recorded adverse reaction.

Use this data to assist in transcribing reactions into the new Adverse Reaction feature. Alerts and ICPC Adverse Effect codes should be discontinued, and all adverse reactions in the future should be recorded using the new feature. This will allow users to be warned of reactions when prescribing medication.

Administrators should run this report. Users without the system right of Clinical Record will not be able to see any of the alert data.

Adverse Reactions New and Modified

Identify records where an adverse reaction has been added or modified within a date range.

Use the report to monitor record accuracy as well as to the identify cases requiring notification to the Australian Adverse Drug Reaction Reporting System.

Alcohol Related Items

Shows all clinical items recorded as alcohol-related between two dates.

Fictitious patients are excluded.

Before providers can capture this information, Alcohol must be set on the File > System Parameters > Clinical tab.

Alert Analysis

Analyses patients by status and counts those with something recorded in the alert of the clinical record or any adverse reactions and those with nothing.

Details are broken down into those with free text alerts, those with no known allergies, those with drug allergies and those with non-drug allergies.

Use this report to analyse compliance with recording of patient drug allergies and other important information.

Conditions and Qualifiers Analysis

Lists all patients who satisfy the biographic criteria with the latest value and date for up to four numeric qualifiers and one non-numeric qualifier. It also lists the latest diagnosis for each patient that belongs to a specified clinical item group. An additional filter allows you to show either all patients (with any item in the clinical item group selected) or only those patients who have an item in the clinical item group selected.

For example, you may choose to select the weight, BMI, HbA1c and cholesterol for women aged over 40 and show the latest diagnosis of diabetes. This will allow you to monitor progress of known diabetic patients and also examine qualifiers for patients without such a diagnosis to identify patients that should be recalled for a consultation.

For those qualifiers not required, select (N/A). Similarly, if you do not need to examine a clinical item group, select (N/A).

Infections Between Two Dates

Shows all recorded infections between two dates grouped by topic and infection.

INR Chart

Prints the current (latest) Target INR (International Normalised Ratio) value and date and displays a table containing historical dates with INR values and warfarin dosage with the associated clinical item comment. For more information, see INR Chart.

Kidney Disease Outcomes

Shows the most recent GFR for any current patient whose most recent ACR was > 3.4 mg/mmol. GFR is recorded in mL/min. Also included are any patients with a diagnosis from the URINARY DISEASE, OTHER group.

The results are grouped into appropriate categories to indicate the level of Chronic Kidney Disease. Definitions are from the Kidney Disease Outcomes Quality Initiative. Also included is a record of patients who are currently or regularly being prescribed an ACE inhibitor or ARB.

Also shown is the most recent diagnosis from the URINARY DISEASE, OTHER group. This can be used to see if a patient's most recent diagnosis is consistent with the latest pathology results.

The report uses the Communicare Central qualifiers of 'ACR (Alb/Creat Ratio)' and 'GFR (ideal body weight)' or 'GFR (actual body weight)' or 'eGFR (Estimated GFR)'.

Note: These results are intended as a guide to patient management only. Care should be taken when interpreting these results.

No Formal Allergy Status Recorded

Lists the patients whio do not have any formal Adverse Reaction Status recorded. The report does not check the "Alerts and Other Information" section.

Export this report to include patient address and phone numbers.

NT Renal Care Summary Report HRN

Report for the NT DHF Renal Care Coordinator showing all patients with a latest GFR less than 60 broken down into each stage of renal failure.

The latest GFR and creatinine values are shown.

When exporting to Excel there are additional data for the most recent ACR, BP, potassium, LDL, smoking status, Hb and HbA1c.

It is similar to the Kidney Disease Outcomes report, except it is based only on GFR values and does not consider ACRs or diagnoses.

Patients with Dx but no Item

Lists all patients who have a clinical item within a selected clinical item group who do not have a specific completed clinical item type or vice versa.

This is a patient-based report. It will list patients once only, regardless of the number of times group clinical items have been recorded for the patient.

Use this report to locate all patients belonging to a particular disease or other group who do not have a specific completed clinical item or for patients with the completed clinical item but no specific diagnosis or other clinical item (e.g. look for patients with diabetes, non-insulin dependent who do not have a completed Cycle of care;annual;diabetes).

Patients with Dx but no Qualifier

Lists all patients who have a clinical item within a selected clinical item group who do not have a specific numeric qualifier within a specified range or vice versa (only the latest qualifier for a patient is considered).

This is a patient-based report. It will list patients once only, regardless of the number of times group clinical items have been recorded for the patient.

Use this report to locate all patients belonging to a particular disease or other group who do not have a specific qualifier of a specific value or for patients with the qualifier but no specific diagnosis or other clinical item (e.g. look for patients with diabetes, non-insulin dependent who have a BMI greater than 30).

Patients with Dx but no Recall

Lists all patients who have a clinical item within a selected clinical item group who do not have a recall for a selected procedure or vice versa.

This is a patient-based report. It will list patients once only, regardless of the number of times group clinical items have been recorded for the patient.

Use this report to locate all patients belonging to a particular disease or other group who do not have a recall for a recommended periodic procedure or for patients with a recall for a procedure but no specific diagnosis or other clinical item (e.g. look for patients with diabetes, non-insulin dependent who do not have a recall for Cycle of care;annual;diabetes).

Procedures and Referrals by Provider

For the selected date range, for each provider, lists:

Provider name
Place mode where the procedures/referrals were done
Name of the procedure/referral
Number of times the procedure/referral was done

Providers who have performed no procedures during the selected period are not listed on the report.

Fictitious patient procedures are excluded.

Use this report to gain an appreciation of the data recording and clinical service activity of each provider.

Qualifier Analysis for Selected Provider

Shows counts of the qualifier usage of all clinical items recorded by a specified provider for a specific clinical item or class, including averages, maxima and minima for numeric qualifiers and individual counts of each reference type qualifier response.

Numeric qualifiers are also summed for a grand total - this is not a sensible value for, say, HbA1c and should be ignored, but is valuable for numeric qualifiers such as 'Amount spent in dollars', and so on.

Use this report to analyse responses to the qualifiers of particular items that belong together. It can also be used to summarise and monitor details that are recorded by a specific provider.

Selected Clinical Item Group Analysis

Counts all clinical items recorded between two dates where the clinical item belongs to a selected clinical item group. The report excludes fictitious patients but includes deceased patients. Filter by patient's locality or locality group where they were living at the time of the diagnosis.

Partially complete procedures, that is, those with required qualifiers that have not been completed, are included in this report.

For each item in the selected clinical item group, the report lists:

Clinical Item Type
Locality of the client's home
Count of the clinical item for clients living at that locality
Total count of the clinical item for all localities
Recording provider

Use this report to report on outbreaks of particular groups of disease, or to count particular types of procedures performed.

Selected Clinical Item Group

Lists all clinical items recorded between two dates where the clinical item belongs to a selected clinical item group. The report excludes fictitious patients but includes deceased patients.

Partially complete procedures, that is, those with required qualifiers that have not been completed, are included in this report.

Use this report to report on outbreaks of particular groups of disease for all localities.

Social and Family History Analysis

Analyses patients by status and counts those with something recorded in the social or family history of the clinical record and those with nothing.

Use this report to analyse compliance with recording of social and family history.

Social and Family History Patients

Analyses patients by status and indicates those with something recorded in the social or family history of the clinical record and those with nothing.

Use this report in conjunction with the Social and Family History Analysis report.

Unconfirmed Diagnoses

Lists all patients who have a condition within a selected clinical item group where the comment contains a question mark (?).

Use this report to locate all patients belonging to a particular disease or other group whose condition may still need confirmation. Where the condition is confirmed, the clinical item should be edited to remove the question mark. Where the condition is not confirmed, the item should be deleted (note that the original progress note will contain evidence of the initial suspicions).

Unconfirmed diagnoses in Communicare are considered for reporting purposes and for calculations such as cardiovascular risk.