Clinical Item Type Properties

Clinical items have a set of structured properties that define the information that can be included in a clinical item, group items, link the item to ICPC-2 PLUS and SNOMED, and enable Communicare to perform advanced calculations and reporting, enable recalls and referrals, control access, and so on.

To display Clinical Item Type Properties, in the Clinical Item Type Maintenance window, double-click an item or select an item and click Edit row iconEdit.

Note: Items with a record number of 1,000,000,000 or greater are centrally maintained by Communicare and have only limited local editing rights.

General tab

On the General tab, set the basic properties of a Clinical Item Type, including:
  • Formal Terms - enter the name or rubric for the item, which is used to give a detailed and exact definition of what the item means and when it should be used. For example, ?Pregnancy or Abrasion;corneal.
  • Natural language - a more natural description of the term. It can be used in letters, for example, where a more user-friendly term is required.
  • Definition - describe the clinical item unambiguously, so that misuse through misunderstanding does not occur. The definition may contain drawings and pictures.
  • Class - select what sort of thing the item is. For example, a record of a Procedure that has been performed, or a Condition that has been diagnosed.
  • Topic - select the topic, that is an arbitrary classification which helps organise a patient's clinical information.
  • Recallable - determines if the item can be used as a recall. This option is only visible for items with a class of Procedure, Immunisation or Referral.
  • Allow Recall Expiry - determines if a user can set a future expiry date for a recall of this type that when passed removes the recall from the patient's record. This option is only visible for items with a class of Procedure, Immunisation or Referral.
  • Enabled - determines if the item can be added to a Clinical Record. Deselecting this option does not remove the item from patient files, but the item can't be used to record new information. Centrally disabled items cannot be enabled locally.
  • Cost - optional value used for reporting and analysis.
  • Viewing Right - right required to view the clinical item.
  • Record for occurrence - record a clinical item with a date and time, or as date only. The default is date only.
    Tip: To enable multiple observations to be recorded for a qualifier in a day, set to Date and Time.
  • Serial Number Mandatory - for items with a class of Immunisation, set to require clinicians who administer a vaccine to record the serial number of that vaccine in the clinical item. Once enabled, clinicians must include a serial number in the clinical item for any new immunisations of that type performed at the health service.
Click Advanced to display the following options:
  • Export Code - a code that may be used when exporting data to another system. For example, it is used when exporting data to the CCDM, in which case it holds an ICPC code. For more information, see Export codes.
  • System Code - an internal code used by Communicare to identify items that are used in calculations. Leave blank unless instructed otherwise. For more information, see System codes.
  • Record No. - Communicare's internal reference number.
  • Critical Referral - enabled when a Referral type item is added or edited. Use to set the item as critical. The standard referrals report can report on these items.
  • Item Interval - the interval required since the last completed clinical item in order to be able to complete the new clinical item. It is used to allow a clinic to define a required period in which an item should be completed. The item can only be completed at the end of the required interval. If an attempt is made to complete this item during the item interval, the item generates a recall with the comment Cannot complete before DD-MON-YYYY.
  • Letter Type - the letter type to be used when adding this clinical item to the patient's record. If not set, Save & Write Letter is not visible.
  • Rule Code - used to identify a program which has enrolment and exit behaviour, such as pregnancy and drug and alcohol programs. For more information, see Rule codes.
  • Picture - add a picture for the clinical item type to the Picture tab of the Clinical Terms Browser. The image must in the format bmp, ico, emf or wmf and be no larger than 60x60 pixels. You must also add an image for the related Clinical Item Topic.
  • Medicare Benefits Schedule:
    Example MBS settings for a clinical item
    • MBS Item No. - the MBS item to be claimed when the clinical item is completed. If there is a number entered here, only a provider with a Provider Number will be able to complete this item, and on completion, the specified item is automatically selected for the provider to claim electronically. If an item is completed by a provider who doesn't have a Provider Number, the item generates a recall with the comment Only a doctor can complete this.
    • Claim Interval - the interval for the MBS item, used when Medicare Australia says that the MBS item cannot be claimed more often than the Claim Interval. If an attempt is made to complete this item by a provider with a Provider Number within the claim interval, the MBS item is not automatically selected for claiming.
  • ICPC 2 Plus:
    Example ICPC-2 PLUS settings for a clinical item
    • Code and Term - ICPC-2 PLUS code for this term. If a clinical item doesn't have a complete code, it doesn't appear on reports that look for this code and decision support is not available.
  • SNOMED:
    Example SNOMED settings for a clinical item
    • Concept Id and Name - mapping between the ICPC-2 PLUS code and the equivalent SNOMED concept. The SNOMED concept ID is validated using the SNOMED terminology server specified in Web Services > SNOMED Terminology. When you enter a valid concept ID of 6-18 digits, Communicare connects to the terminology server, pulls the correct concept name from the server and updates the concept name and status.
      • Browse iconBrowse - click to connect to the terminology server configured for your organisation where you can search for the relevant concept ID.
      • Validate buttonValidate Status - click to validate the concept ID and update the concept name and status from the terminology server. Only verified concept IDs have a concept name: invalid concept IDs cannot be saved.

      If a clinical item doesn't have a SNOMED concept ID, it doesn't appear on reports that look for this concept ID.

      Central items mapped to SNOMED CT are mapped centrally; map only local clinical items using these settings.

Keywords & Qualifiers tab

The keywords grid lists the terms that can be used to locate this item or adds the clinical item to a shortcut button. For more information, see Clinical Item Keywords and Shortcuts.

The qualifiers grid lists any qualifiers that are linked to this item. Qualifiers add additional meaning to a Clinical Item Type. A Clinical Item Type can have any number of qualifiers associated with it. For example, the clinical item Pregnancy;confirmed may have associated qualifiers such as Date of LNMP, Gestation, Foetal heart rate, and so on.

The qualifier types table shows the following information:
  • Order - a number used to sort the qualifiers
  • Qualifier - qualifier term
  • Unit - units in which the qualifier is measured, for example, Date, weeks, bpm.
  • Required:
    • Qualifiers cannot be marked as Required if the clinical item type is not recallable, nor can they be used if the clinical item type is a referral.
    • If a qualifier is not required, it cannot have a required interval.
    • When a clinical item is recallable and has required qualifiers, making the item not recallable clears the required flag on the qualifiers.
    • When designing a clinical item that has required qualifiers, note that the behaviour of that qualifier does not commence until the day after the qualifier was enabled. To see the effective date, right-click and select Show Hidden Columns.
  • Highlight Blank - set to highlight a qualifier when it has no data. This is useful to draw attention to important values on very long forms.
  • Enabled - use to hide a qualifier that has been used in the past, but is no longer needed. No patient data is lost and the data is visible when older items are edited. However, the qualifier will not appear for use in the future. Disabled qualifiers are displayed in grey.
  • Min Age and Max Age - determine whether the qualifier should be shown in the clinical item. A patient who is below the minimum age or above the maximum age will not have the qualifiers shown when that item is added.
  • Show Tab - determines whether this qualifier should appear on the clinical item as a new tab. Note that this field can only be set for qualifiers that are of the Unit type Title.
    • This field only applies when the Allow Tabs in Clinical Items system parameter is on. This field cannot be changed for qualifiers on centrally maintained clinical items.
    • Title type qualifiers do not collect data. They are displayed in bold in this window to facilitate design.
    • Where a qualifier is sex-specific, the row is coloured pink or blue depending on the sex. Qualifiers with a sex that does not match that of the patient are not displayed when the clinical item is added.

To edit a qualifier, click Edit Qualifier Types.

Keywords can be added, deleted or changed in the top grid. The bottom grid displays all the clinical item types that use the keyword selected in the top grid. The bottom grid can be used to add or delete clinical item types to a keyword. See Clinical Item Keywords for more information.

Tip: For a recall to be included in the manual recall lists, for a clinical item type with a class of Procedure, Immunisation or Referral:
  • To include the item in the manual recall list in the clinical record, add the keyword $Recall
  • To include the item in the manual recall list for incoming results, add the keyword $IxRecall

To edit a keyword, click Edit Keyword Table.

Groups tab

The Groups tab shows the groups to which the clinical item type belongs, for reporting and analysis purposes.

To add groups and edit or delete existing groups, click Edit Groups Table.