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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.
Clinical Support
Investigations and documents
Communicare receives pathology and imaging results, letters and other documents electronically and sends documents and letters electronically using HL7 messages.
Documents
Documents can be received from external sources, sent from Communicare or added to Communicare.
Send documents
Using Communicare you can send documents electronically.
Writing letters and referrals
You can write letters and referrals from a patient's clinical record. You can also write letters from Documents and Results or from File > Documents.
Send eReferrals
Communicare can create and send eReferrals in the CDA format compliant with eHealth standards in Australia.

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.
- Medications
  This topic covers all Medications Management functionality within Communicare.
- Clinical Support
  - Investigations and documents
    Communicare receives pathology and imaging results, letters and other documents electronically and sends documents and letters electronically using HL7 messages.
    - Documents and results summary
      Use the Documents and Results window to display internal, incoming and outgoing documents and incoming results for any patient at your service.
    - Investigations
    - Documents
      Documents can be received from external sources, sent from Communicare or added to Communicare.
      - Read-only documents
        Read-only documents in Communicare cannot be modified under any circumstances.
      - Add documents
        Documents are the electronic reflection of printed material that is important enough to be recorded in the patient's file. Only add documents to Communicare that cannot be encoded using normal clinical items.
      - Send documents
        Using Communicare you can send documents electronically.
        Writing letters and referrals
        You can write letters and referrals from a patient's clinical record. You can also write letters from Documents and Results or from File > Documents.
        Selecting a template
        Use the Select Document Template window to select a template when creating a document or writing a letter.
        Send eReferrals
        Communicare can create and send eReferrals in the CDA format compliant with eHealth standards in Australia.
        Letter viewer
        Use the Letter Viewer to view the contents of a document without printing it.
        Discharge Summaries
        Communicare can create and send Discharge Summaries either in the CDA format (compliant with eHealth standards in Australia) or in a less constrained RTF format. RTF format Discharge Summaries cannot be sent to MeHR, whereas CDA format documents can be sent to either My Health Record or MeHR.
      - Receive documents
        Using Communicare you can receive documents electronically.
      - Delete documents
        Use the Browse Documents window to delete documents.
      - Clinical Document Architecture (CDA)
        Communicare can send and receive CDA documents.
      - Combined Address Book
        The combined address book stores local address book entries and allows you to search multiple, online provider directories.
      - EPD address book
        The EPD address book was replaced in Communicare V22.2 by the combined address book to support searching the local address book and online provider directories simultaneously, and secure message exchange.
      - Secure Messaging
        Secure Message Delivery (SMD) is the government standard for sending medical documents and messages securely and safely.
  - Referral Management
    Manage incoming internal and external referrals from a single list.
  - Birth Notifications
    For customers who belong to the Western Australian Country Health Service, use the Birth Notifications module to manage notifications related to births from a single list.
  - Recalls
    Recalls are the elements that make up a care plan. Recalls can be either generated automatically by Communicare or manually created by the user.
  - Datasets
    Datasets are a user-friendly coding system, giving health professionals a standardised way to record data and report on data entered in a patient’s clinical record.

Send eReferrals

Communicare can create and send eReferrals in the CDA format compliant with eHealth standards in Australia.

An eReferral is a referral of a subject of care such as a patient or client from one health care provider to another.

The eReferral Clinical Item must be enabled. See Clinical Item Types.
Encounter places must have an HPI-O configured.
The current Provider must have an HPI-I.
The patient must have an IHI.
Secure Messaging must be configured if you plan to send via secure messaging. See Secure Messaging.
My Health Record must be configured if you plan to upload to the My Health Record. See My Health Record.

eReferral CDA document data sections:

Referee - the specialist to whom the patient is being referred, populated from the Provider referred to field in the Referral class clinical item.
Medical History - the past and current medical history of the patient, including problem and diagnosis, and any medical or surgical procedures recorded in their clinical record, populated from any procedure and condition clinical class items recorded on the main summary screen.
Medications - current medications recorded in Communicare. See Medication Summary.
Adverse Reactions - lists any adverse reactions recorded for the patient in Communicare. See Clinical Record - Summary Tab.
Diagnostic Investigations - contains any investigation results for investigations that were received and matched to the patient's record in the 30 days prior to the referral date.

To create and send an eReferral:

Open the clinical record for the patient for whom you want to create an eReferral.
Create a Referral class clinical item. Search for the keyword referrals.
Add the required details.
Click Save & Create eReferral.
The View eReferral window displays the required information based on the data entered in the eReferral clinical item.
1. Use the tree to exclude any clinical information listed that is not relevant, or needs to be excluded from the document.
2. In the Details panel at the bottom of the window, from the To field select a document recipient.
3. When ready, save, print, or upload to My Health Record.
4. Send the eReferral securely using Secure Messaging. Click Send Secure.
5. Click Save and Upload to My Health Record. If you have previously uploaded an eReferral, set Supersede to replace the previous My Health Record document with a new document from Communicare.

15 March 2024