Detailed GPMP Notes (Item 721)

GP MANAGEMENT PLAN - [Condition Name] **Patient Details:** - Full Name: [Enter the patient’s full legal name as it appears on official documents.] - Date of Birth: [Enter the patient’s date of birth in the format DD/MM/YYYY.] - Medicare Number: [Enter the patient’s Medicare number, if applicable.] - Does the patient identify as Aboriginal or Torres Strait Islander: [Enter "Yes" or "No" and clarify if applicable.] - Address: [Enter the patient’s full address, including street, city, and postcode.] - Home Phone: [Enter the patient’s home telephone number.] - Mobile Phone: [Enter the patient’s mobile phone number.] **Date GPMP Completed:** [Enter the date when the GPMP is prepared in the format DD/MM/YYYY.] **Date of Previous GPMP:** [Enter the date of the previous GPMP, if applicable.] **Details of Patient's Usual GP:** - Name: [Enter the full name of the patient’s usual GP.] - Qualifications: [List the GP's qualifications, including their degree and certifications.] - GP's Address: [Enter the full address of the GP's practice.] - GP's Phone: [Enter the phone number of the GP's practice.] - GP's Fax: [Enter the fax number of the GP's practice.] **Assessment of Patient** Patient Identified Problems / Health Care Needs: - Diagnosis: [Enter the main diagnosis or condition being managed. For example, "COPD," "Hypertension," etc.] - Date of Diagnosis: [Enter the date the diagnosis was made in the format DD/MM/YYYY.] **Medical / Surgical History:** [Provide a comprehensive summary of the patient’s relevant medical and surgical history, including chronic conditions, any past surgeries, hospitalizations, and prior treatments. Focus on health conditions that are relevant to the current diagnosis and management plan. List conditions in bullet points or short descriptions.] **Medications:** [List all the current medications the patient is taking, including the medication name, dosage, and frequency. Make sure to include any recent changes to the medication regimen and highlight any newly prescribed or discontinued medications.] **Allergies:** [Enter any known allergies or sensitivities the patient has. Specify whether the allergies are to medications, foods, environmental factors, or other substances. Include a brief description of the reactions if applicable.] **Immunisation History:** [Provide a summary of the patient’s immunisation history. Include details of vaccinations, whether they are up-to-date, and any relevant immunisation records. Specify the date of the last influenza vaccination, pneumococcal vaccination, or any other relevant vaccinations for the condition.] **Smoking History:** [Record the patient's smoking history. Specify whether they currently smoke, used to smoke (include pack-years if known), or have never smoked. If the patient is a current smoker, mention how many packs per day and for how many years. Also, include any history of smoking cessation attempts.] **Planned Review Date:** [Enter the date for the next review of the GPMP. It should typically be at least 6 months from the date the plan was created. The review date should be based on clinical guidelines or the patient’s individual needs.] **GPMP Added to the Patient’s Records:** [Enter "Yes" or "No," confirming whether the GPMP has been added to the patient’s medical records.] **Copy of GPMP Offered to Patient:** [Enter "Yes" or "No," indicating whether a copy of the GPMP has been offered to the patient for their records.] **Patient Understanding and Agreement:** "I understand this Management Plan recommendations and agree to the outlined goals." Patient Signature: [Enter patient’s signature, if applicable.] Date: [Enter the date the patient signed the GPMP.] "I have explained the steps and costs involved, and the patient has agreed to proceed with the service." GP Signature: [Enter the GP’s signature or digital confirmation.] Date: [Enter the date the GP signed or confirmed the plan.] **Current Health Need/Problem:** [Describe the patient’s current health needs or concerns in relation to their diagnosis. Focus on the specific issues the GPMP is addressing, such as symptom management, risk factor modification, or treatment adherence. This may include any recent changes in symptoms or the condition’s progression.] **Goal:** [State the primary goal(s) for managing the condition, making sure the goal is measurable and specific. This could include reducing symptoms, preventing exacerbations, improving quality of life, or achieving a particular clinical target (e.g., better lung function, lower blood pressure).] **Agreed Action by Health Professionals and Patient** 1. General - Patient's Understanding of the Condition: [Describe the patient’s current understanding of their diagnosis and management plan.] [Explain the steps taken to ensure that the patient understands the nature of their condition, including how they will manage it moving forward.] [Provide specific details on educational resources offered to the patient, such as pamphlets, websites, and any direct education provided during consultations.] [Note any follow-up appointments or discussions scheduled to reinforce understanding.] 2. Lifestyle - Quality of Life: [State the goal of assessing the impact of the condition on the patient’s quality of life.] [Describe the tools used to assess quality of life, such as questionnaires like the COPD Assessment Test (CAT) or other relevant scales.] [If applicable, specify how often these tools will be used to monitor the patient’s quality of life over time.] - Nutrition: [Detail the educational efforts to ensure the patient maintains a balanced diet and healthy weight.] [Specify what aspects of nutrition are being focused on, such as caloric intake, protein needs, or micronutrients (e.g., vitamin D and calcium).] [If the patient has any dietary restrictions or special needs, include them here.] [Indicate any referrals to a dietitian or nutritionist if applicable.] - Physical Activity/Exercise: [Outline the goals for increasing physical activity, focusing on maintaining or improving the patient’s ability to perform daily activities.] [Describe the recommended types of exercise (e.g., daily walking, low-impact activities) and the targeted frequency (e.g., 30 minutes a day, most days of the week).] [If applicable, refer to any structured exercise programs, including pulmonary rehabilitation.] - Smoking Cessation: [Describe the smoking cessation goal and any support strategies in place for the patient who smokes.] [Include behavioral therapy, medication support (e.g., nicotine replacement therapy or prescription medications), and other interventions to assist in quitting.] [Provide contact details for Quitline or local support programs.] - Energy Conservation: [Explain the patient education provided on energy conservation techniques.] [Describe how the patient will be guided to conserve energy during daily activities, including pacing strategies or the use of assistive devices.] [Include any referrals to occupational therapy or other specialists who can assist with energy conservation techniques.] 3. **Biochemical** - Spirometry: [State that spirometry will be used to assess lung function and monitor disease progression.] [Specify the frequency of spirometry assessments (e.g., annually, semi-annually) and the goal of monitoring FEV1/FVC to classify the severity of the patient’s COPD.] [Note if a baseline spirometry has already been completed, and provide expected timelines for future assessments.] 4. **Medication** - Medication Review: [Describe the patient’s ongoing medication review process, ensuring they understand how to take their medications properly.] [List any medications the patient is currently on and any changes that have been made to their medication regimen.] [Ensure the patient’s inhaler technique is checked and provide education on proper inhaler use to avoid side effects.] [If applicable, specify if a Home Medication Review (HMR) or Detailed Medication Management Review (DMMR) will be scheduled.] - Immunisation: [Confirm that the patient is up to date with necessary vaccinations, such as influenza and pneumococcal vaccines.] [Include the dates of the last vaccinations and the next scheduled vaccinations.] [Note if there are any specific immunizations recommended for the patient due to their condition.] 6. **Complications** - Monitoring of Health Conditions: [State that the patient's health will be monitored, particularly if they are on treatments that could increase the risk of complications.] [Schedule any necessary tests and provide guidance on maintaining overall health through lifestyle management, diet, exercise, and medications where appropriate.] [Include any referrals to specialists or clinics if necessary.] 7. **Mental Health and Wellbeing** - Depression, Anxiety, and Stress: [Explain that the patient will be assessed for mental health concerns such as depression, anxiety, and stress, which can affect patients with various health conditions.] [Include any relevant screening tools or questionnaires used to assess these symptoms.] [If necessary, refer the patient for psychological support, including therapy, counseling, or other mental health services.] - Social Isolation and Emotional Wellbeing: [Note that the patient will be encouraged to participate in social support networks to reduce isolation and improve emotional well-being.] [Provide information on available support groups or community activities, including contact details for local or online support services.] [If applicable, include information on resources available through the healthcare system, such as social workers or peer support programs.] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, do not state that the information is not available; simply leave the placeholder blank or omit it completely. Use as many lines, paragraphs, or bullet points as necessary to comprehensively capture all relevant details.)