Clinical items

A clinical item is the basic element of a clinical record.

Clinical items are an essential building block for providing a care pathway with the clinical record workflow.

Clinical items are developed using standards and guidelines that inform the care pathway and the data that must be recorded.

Using clinical items, clinicians record a clinical event in a patient's record using qualifiers to ask relevant clinical questions and record responses in a structured way. The structured data that results informs automated recalls, charts, reports, letters, care plans, investigations, medications and Medicare submissions.

Clinical items are included in Communicare by default. Items can be added for your health service or customised. For more information about customisations, see Clinical Item Maintenance.

All clinical items

Every clinical item:
All clinical items include the following fields:
  • Comment - optional free text (or, for Chronic and Acute Medications, the name of the medication). Long comments may be truncated in some reports and grids. Double-click the item to display the full comment.
  • Date/Time - the date and time at which the clinical item actually occurred, which may be Performed Date, From Date, Date referred, Date admitted, and so on. Each clinical item can be configured to be recorded with either a date only or both a date and time by your Communicare Administrator in Clinical Item Type Properties. The default is date only.
  • Display on Summary - this item type should be added to the Clinical Summary. Deselect to remove an item from the clinical summary. This is not visible for the Alert class type.
  • Display on Obstetric Summary - for female patients set 'Display on Obstetric Summary' to add or remove an item from a patient's obstetric summary. This is not visible for the Alert class type.
  • Reason for Encounter - if enabled, set to indicate that this clinical item provides the reason for the encounter and if Reason For Visit is also enabled, one of up to four reasons for the patient's visit. This is not visible for the Alert class type.

Items that were recalls

Clinical items that were recalls include the following fields:
  • Planned Date - the date the Recall clinical item is due
  • Expiry Date - the date the Recall clinical item is due to expire. This is enabled only if your Communicare Administrator has allowed this behaviour for this recall type.
  • Responsibility - the users responsible for completing the recall
  • Cancellation reason - visible if the item is a cancelled recall

Some clinical items

Any clinical item may have supplementary qualifiers. These collect a variety of data in the form of dates, drop-down lists, free text, images, numbers, memos, Yes/No tickboxes and references to another patient.

Numeric qualifiers may have a range of allowed values defined. These values appear in brackets after the units and cannot be exceeded.

Calculated qualifiers are qualifiers that can be calculated from a patient's existing information. A Calculated qualifier will have a Calculate or a Recalculate button underneath the value. Click the button for Communicare to automatically calculate the qualifier's value.

To the right of the qualifiers will be the date and value of the most recent same qualifier type recorded for that patient. There may also be a button to see all previous values of that qualifier type.

Clinical items of a particular class

Other attributes will appear depending on the class of the clinical item. See Clinical Item Attributes.

Clinical items linked to clinical programs

Some clinical items can be used to enrol or exit patients from a clinical program. For example:
  • For drug and alcohol treatment service programs, Alcohol/Other Drug respite enrolment and Alcohol/Other Drug respite exit, Alcohol/Other Drug treatment enrolment and Alcohol/Other Drug treatment exit
  • For Headspace programs, Headspace;Enrolment and Headspace;Closure
  • For home support programs HACC/CHSP Enrolment and HACC/CHSP Exit
  • For integrated team care programs, ITC Enrolment and ITC Exit
  • For primary mental health contacts, PMHC Episode Start and PMHC Episode End
Enrol patients into a clinical program using the enrolment clinical item, then add activity items as required. When the clinical program is complete, to remove the patient from the program, either complete the exit recall or add the matching exit clinical item to the patient's clinical record.
Tip: You cannot add activity items until after a patient has been enrolled in a program. However, you can still add activity items after a patient has been exited from a program. This allows for genuine backdating of clinical items. For example:
  • If you are using an offline client and your clinical program enrolments and exits have got out of step, you can backdate an exit.
  • If items are out of sequence, correct the items.
  • For a patient who exited last week, record an action from two weeks ago.

Read-only clinical items

Some clinical items may be created and maintained in other systems and integrated into Communicare. These items can be marked as read-only by Customers or Integrators to prevent them from being edited. Read-Only items cannot be edited, deleted, cancelled or completed in Communicare.