Recording a Service

For each patient encounter, record a service.

Recording services from the Service Recording window

To record a service from the Service Recording window:
  1. To open the Service Recording window, click Service Recording.
  2. When a patient arrives, if they have an appointment booked, click Check In.
  3. If the patient is a walk-in or you are not using appointments, click Add and select the patient.
  4. In the Session Selection window, select the walk-in session or click Extra.
  5. In the Service Record window, set Medicare to bulk bill the patient, or Private otherwise.
  6. From the Providers list, select a provider.
  7. Enter encounter place and mode information. If a default provider, mode or place has been set on the main toolbar (see Preselecting the Provider), these details are already entered.
  8. Click OK.

The patient status is changed to Waiting.

By default, the date of service is today. You may not have details of patient arrival unless waiting times are being recorded for your particular mode and place.

Recording services by opening the Clinical Record

Whether or not your health service books appointments, or records waiting times, opening a clinical record starts a service.
To record a patient's arrival in the clinical record:
  1. Click Clinical Record iconClinical Record on the main toolbar and select the patient.
  2. If the provider, mode and place (see Preselecting the Provider) are set and there is no other service recorded for the patient today, the clinical record is displayed and the service starts.
  3. If there is a service already recorded today, in the Select Service window:
    • If you want to continue an earlier service, select that service and click Yes - Open selected service. If you are an additional provider, your name will be added to the service.
    • If this service is clearly another service provided independently of any earlier service, click No - Start new service.
  4. If all the necessary details haven't been provided, in the Provider, Place and Mode selection window:
    1. From the Provider list, select your name.
    2. From the Place and mode list, select your encounter place and mode.
    3. To save these details on this computer, click Remember These Details.
    4. Click OK.

In the clinical record, the status bar at the bottom displays details of the current service, including provider.

You can now enter details of your service, such as clinical items, medications and so on.

If you want to change or add providers:
  1. Double-click the current service details.
  2. In the Service Record window, on the Detail tab, select the required providers.
  3. Click Save.

Ending a service

To end a service, close the clinical record and complete the followup tasks.
To end a service:
  1. In the clinical record, click Close iconClose.
  2. If there are any prescriptions that have not been finalised or printed, a Confirm window is displayed.
    • If you want to finalise or print the prescriptions:
      1. Click Yes. The Finalise Prescriptions window is displayed.
      2. Finalise the prescriptions or print the medications as required. For more information, see Finalise Prescriptions.
    • If you don't want to finalise the prescriptions, click No.
  3. If you use medication requests and the latest non-cancelled request was stopped today and a pickup location isn't set, or there is a pickup location set but a medication request has never been created, a Confirm window is displayed.
    • If you want to create a medication request for the patient:
      1. Click Yes. The Medication Requests window is displayed.
      2. Add a new medication request as required. For more information, see Medication Requests.
    • If you don't want to create a medication request, click No.
  4. In the Service exit window, click Yes iconYes - This service is now complete. Alternatively, if you want to pause the service because the patient will now see another provider, click Pause iconNo - Patient will see another provider. See Service Exit Dialog Form for more information.
  5. If you are registered with Medicare and online claiming is enabled for your health service, on the Medicare tab of the Service Record window:
    • If the policy of your health service is to have a receptionist process Medicare claims, click Save.
    • If you want to submit Medicare claims yourself, check that the Default Claiming Provider is correct, select the relevant Medicare items and click Claim now. For the current service, you can add or change providers by clicking the yellow triangle or double-clicking on the current service details (see above).
    For more information about sending a claim to Medicare, see Submit a claim to Medicare.

The service is complete and you can start another service.

Tip:
If you don't ever submit Medicare claims and don't want to see the Medicare tab when you close a service record:
  1. Select File > Providers.
  2. In the Providers window, double-click your name.
  3. In the Provider window, deselect Show Medicare Claim Tab?.
  4. Click Save.

Recording services for a previous day

If required, you can record services for a previous day for a service provided to a patient by you.
To record services for a previous day:
  1. Click Clinical Record on the main toolbar and select the patient. A service for today is generated.
  2. Double-click the current service details in the status bar. For example:Example status bar
  3. In the Service Record window, in the Date of service calendar, select the correct date of the service.
  4. Click OK.

You can now enter clinical information for that service, which are recorded in the patient's Progress notes with the date you selected.

You can also record services for a date prior to today in the Service Recording window, but you cannot enter clinical information if you use this method.

Editing clinical information for a service

If you are the provider who recorded a service, you can edit the clinical information.

To enter clinical information for an existing service:
  1. Click Clinical Record on the main toolbar and select the patient.
  2. On the Progress Notes tab of the clinical record, in the contact list in the left pane, drag the service you want to edit to the service details pane on the right.
  3. In the Select a different service window, click Yes - Open Selected service instead of current service.

Communicare exits today's current service, so the old service can be opened. The old service is opened and you can now update details in the old service.

When you close the clinical record, in the Service exit window, if you aren't providing a service today, click Ignore - No service has been provided.

Recording the length of the service

Communicare records how long each provider spends on a service. The time spent providing a service is recorded next to each provider. For example, one provider spent 30 minutes with a patient whilst another spent only 5 minutes with the patient on the same service. If you do not manually add or change the time, Communicare records the time that the clinical record was open in that provider's name automatically.