A client's record

An administrator sets up which fields exist under Settings.

• Each field says underneath it who can see it. Most say “Office only”; one that has been opened up names who else reads it — the carer on the shift, the portal, or both.
• A field opened to the carer appears on the brief they must read and acknowledge before they can clock on, so what you type there is what somebody reads standing at the door. Only carers rostered with this person ever see it.

A letter on your own letterhead — a justification or summary to a surgeon, GP or plan manager, or a reassessment letter for this client.

• Finalising is final. It renders the PDF, files it in this record's documents and locks the text — because a copy has left the practice. To change a finalised letter, write a new one.
• It signs as whoever presses Finalise, with that person's position and AHPRA number stamped on as at that moment.
• “File it under” decides where the PDF lands in this record's documents. Your own categories are offered — if you already keep a category for letters to doctors, use it rather than starting a second one.

Pick what kind of letter — to the GP or referrer, a referral, a plain-words summary for the client or their family, or a letter of justification for funding — say who it is for, and the first draft is written from this record: the profile and the last twelve months of notes, forms, incidents, medication entries and wound assessments, each fact dated. It opens in the letter editor as a draft on this record.

• The words come from what was recorded, with the date, and a letter of justification asks only for what the notes say was recommended. Read every line before you sign it — it goes out under your name and registration.
• The record is read by an AI service overseas to write the draft, the same as “Ask about this record”; the sentence above the button says where.
• The list shows which letters started as a draft from the record, on finalised letters too.

Attach a coordinator, plan manager, GP or funder from the shared directory to this client, and say what they are to them.

• Unlinking removes the link only. The contact stays in the directory, still linked to everyone else.

The care plan: goals, supports, decision-making, communication and the review date.

• Supersede an old plan rather than editing it, so the history of what was agreed when stays readable.

A written report against the plan — what changed, what worked, what is next.

• Reports are often read by a funder.

• A link works for 14 days and can be used once. Creating a new link cancels the one still awaiting a signature — only the newest link works.
• The wording follows the funding on the agreement — NDIS, aged care or private. Check the funding type before you send.

Send this client, or whoever is helping them, the registration form as a private link: what they send lands in the referrals queue marked as being for this record, for you to review before anything here changes.

• Only one link per record is live at a time — a new one cancels the older one still awaiting answers.
• The form arrives as a referral. Attach it to this record from the referrals queue rather than creating a second record.

What is funded, over what dates, and how much of each allocation.

• The dates drive every funding check on the roster. An agreement that ends mid-week makes shifts after it read as unfunded.
• An NDIS plan can be managed two ways at once: set a category's Managed by (for example NDIS — plan managed) and that category's work is invoiced on its own route — to the plan manager named on the agreement — while the rest stays as the plan.
• A repeating shift is checked across every week it books; Copy week, extending a series, changing its later weeks, a bulk edit and a rebook say afterwards which limits they took over. A shift across midnight on Sunday counts in both weeks for the hours in each.

A medication on the list, including PRN.

• It records what is prescribed and what happened at each dose.
• Packed in a Webster pack at: tick the times the pharmacy packs this medicine at (Breakfast, Lunch, Dinner, Bedtime), as its pack sheet lists them. Leave them all unticked for a medicine given from its own box.
• What it is for: choose one of the person's conditions (from their Medical history tab), write it in your own words, or both.
• First day and Last day are the course: a visit lists the medicine on those days and the days between. Leave both empty for a medicine given until it is stopped.
• Next review: the day the medicine is next reviewed.

Give the client themselves, or someone in their family, their own portal sign-in: their name, the email address they read, and how they are related.

• From their contacts fills the name, email and relationship from someone already on Personal contacts.

Every dose recorded for this person between two days, as a spreadsheet, with how many of each outcome were recorded.

• The days are both included, two years at most; it starts at the last 30 days.

Record that a medicine was reviewed — today, by you — with the day of its next review and a note.

• It records that a person reviewed the medicine, in their words.

A condition (with when it was diagnosed and whether it is current), a past procedure (with when), or an allergy (with the reaction and how severe), on the Medical history tab.

• A date is kept as you know it: the year (2015), the year and month (2015-03) or the whole date (2015-03-14).

• Releasing the hold puts the shifts back. Anything already invoiced is untouched.

Somebody in this client's support network — family, GP, coordinator.

The form a client signs before a meeting naming them can be recorded, signed on screen or uploaded on paper.

• Consent can be withdrawn at any time; that stops further recording and keeps the record that it existed, because it covered what was already transcribed.

The form a client gives one kind of permission on — clinical photographs, sending their information to a GP or funder, or being reviewed over video. Signed on screen, uploaded on paper, or recorded as given verbally.

• Recording a consent again creates a new entry rather than overwriting the old one, so a lapse and a renewal both stay readable.

Stop one kind of permission for this client — photographs, information sharing, or telehealth — from this moment on.

• The consent stays on the record marked withdrawn rather than being deleted, because it covered what was already done under it.

A goal being worked towards, with progress and a target date.

A task that should appear on every shift for this person.

Pause somebody temporarily — hospital, respite, travelling — so they stop appearing as active.

• A hold with an end date reverts on its own the day after it passes, back to whatever they were before. Leave the date blank for an open-ended hold and end it by hand.

End supports for this client, or record that they have died — and bring them back in one click if they return.

• Exiting keeps everything — the record, the notes, the invoices. It only stops them appearing when you book new work and in the lists the office works from.
• When their supports have ended, shifts already booked STAY on the roster. Exiting warns you how many there are; cancelling them is a separate decision, because a cancellation has pay and notice attached.
• “They have died” asks for the date, then lists what else it will do before anything is done: close the client's open episodes on that date, end their funding at it, and cancel their visits from it (or from today, if that is later). Visits already worked or invoiced, and visits shared with other clients, stay as they are.
• The cancelled visits are a roster hold, so if a death was recorded against the wrong person, Release on their page brings every visit back. An episode is reopened, and a funding end date changed, on the episode itself.
• Recording a death needs the access to do each part by hand — close episodes, end funding, cancel visits.

The short need-to-know that rostered staff DO see, unlike office-only notes.

Record what happened with a dose: given, refused, missed or unavailable.

Record what was assessed in one risk domain, with the date.

• This stores what a person judged.

Stop any further recording for this person.

Put one of your allied-health providers on this client's team: from which day, until which day, what for, who made the referral and how.

• Who made the referral starts as you. Change it to whoever actually referred them — a name, or a role such as their GP. Who and how are asked for every time, so the record always says both.
• The last day starts as the end of the client's current agreement.
• A provider with something lapsed or missing can still be added. Corella says what, so it can be chased.

Move the last day, for example when the agreement is extended, change what the provider is there for, or correct who made the referral and how.

Take a provider off the team today, with the reason if you want to give one.

• If your allied-health portal is open, the provider stops seeing them straight away, and the next morning is emailed, from you, that the referral has ended, when your emails are switched on. The same happens on its own after the last day.

Record the day the client agreed that the providers on their allied-health team may see each other's notes, and how they agreed.

From the next page each provider sees only their own notes again. The consent and its withdrawal stay on the record.

A provider's visit to this client: the day, from and until, where, and what for. It shows on the team, on Allied health → Appointments and in the provider's own portal.

• If the time doubles up — a shift for the client, another provider's appointment, or the provider's own — you see it before anything is saved. Change the time, or Book anyway; the double-up is kept on the appointment.
• It must fall within the referral's days.

It stays on the record as cancelled, with who and why. Ending a referral cancels its appointments still to come.

Tick the documents on this client's record that the provider needs for this referral, such as the care plan or an assessment. They see each one in their portal.

• It stays shared until you withdraw it or the referral ends. Withdrawing keeps the record of who shared it and when.

Every note about this client for the days you choose — two years at most — oldest first, with each note's sections, who wrote it and when, the shift it is about and its addenda. Download CSV opens in Excel; Make a PDF saves it in their documents under Reports and tells you when it is ready.

• Check what you hand on before it leaves the office.