GP CHRONIC CONDITION MANAGEMENT PLAN
ITEM: GP Chronic Condition Management Plan- MBS Item 965    
PATIENT DETAILS:	GP DETAILS:	
		
DATE CARE PLAN PREPARED:  Insert date
PATIENT CONSENT OBTAINED:   Insert consent obtained 
PROBLEM LIST: (Health summary of current conditions)
ALLERGIES:   Allergies recorded
CURRENT MEDICATIONS:  Populate current medications
Smoking    smoking status
Biometrics:  Insert Weight, Height, BMI, BP (sitting and standing) O2 sats, Pulse, Temp etc
SERVICE PROVIDERS: WHAT OTHER CARE PROVIDERS ARE INVOLVED
NAME	SPECIALITY	CARE PROVIDED	
Dr. Frederick Foote	Podiatrist	Foot care	
Mrs. Fiona Glass	Ophthalmologist	Monitor Glaucoma	
Dr. Timothy 	Diabetes Educator	Education and support	
Miss Fran Pushup	Exercise Physiologist	Implement/supervise exercise	
Dr. Ian Hormone	Endocrinologist	Manage Diabetes	
PROBLEMS/ NEEDS, GOALS AND PLANNED ACTIONS
Current Health Needs/ Problems	Goal	Planned Actions/ Tasks	Service Provider Responsible	
[Main condition]	Increase patient's understanding of Chronic condition.	Patient education.
	GP	
Self-management	introduce self-management where appropriate	Counselling, support, education.	GP, Allied Health, Specialist	
General health monitoring.	Monitoring of general health	Review patient's status.
•	Measure weight, height, BMI, blood pressure.
•	Tests specific to this chronic condition	GP
How often?
•	once every 6-12 months.	
Medications.	Correct use of medication, with minimal side-effects.	Education about medications. Home medicine review if needed.	Pharmacist	
Future complications. Reduce risk of hospitalisation.	•	To prevent/minimise the long-term effects of Chronic Pain on body and everyday life. 
•	To manage medication.	•	Annual complication assessment & review. 
•	Adjustment of medication.	Consultant physician	
Smoking	complete cessation	support, educate, counsel	GP	
Need for healthy diet.
 
	To maintain a healthy weight & healthy, adequate nutrition.	Increase understanding of healthy eating. Review diet.	Dietitian / Health Educator & GP	
Need for physical activity.	To exercise for at least 30 minutes, most days of the week.	•	To establish a regular exercise routine. 
•	Reinforce activity.	•	An exercise program of patient's choice.
•	Reinforced by GP.	
Alcohol	low risk alcohol consumption is ZERO	assess medications for potential alcohol interactions - advise patient. Encourage patients to abstain from alcohol at all or limit intake to 2 or less standard drinks a day. 	GP.	
Weight	Waist measurement:
Male< 94 cm
Female < 80 cm
BMI <25 kg/m2	assess and monitor BMI and WC, set goals, review, educate	GP	
Psychosocial burden of chronic condition, impact on social life.	prevent adverse effects of chronic condition on everyday life	assessment, education, support, referral.
	GP	
PATIENT AGREEMENT TO THE GOALS OF THE CARE PLAN: AGREED
I understand the above Care Plan recommendations and agree to the outlined goals.
Copy of Care Plan given to patient:  Yes    
Recommended review date:  3 OR 6 MONTHS
Reminder added:  Yes

Consent to upload to MyHealth Record:     Yes/No                 Uploaded:  Yes/No