APC GPCCMP template

**GP Chronic Condition Management Plan (GPCCMP)** **Patient Name:** [full patient name] **DOB:** [date of birth] **Date of Plan Preparation:** [plan preparation date] **Prepared by:** [treating GP's full name] **Review Date:** [date of next review] **1. Description of Chronic Conditions and Associated Health Care Needs** **Chronic Conditions:** [each diagnosed chronic condition with relevant clinical details such as diagnosis name, clinical data, investigation results, and dates of diagnosis or reviews] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs. Repeat for each condition.) **Associated Health Care Needs:** [list of health care needs associated with the chronic conditions such as medication needs, monitoring, education, referrals, and preventive care] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) **Current Medications:** [list of current medications including name, dose, frequency, and start date] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) **2. Health and Lifestyle Goals (SMART Goals)** [clinical area and related SMART goal including specific, measurable, achievable, relevant, and time-bound targets with action plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points. Repeat for each SMART goal.) [nursing or general practice involvement relevant to the goals such as wound care, immunisations, health coaching] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) **3. Actions to Be Taken by the Patient** [list of actions the patient is advised to undertake such as medication adherence, attending appointments, lifestyle modifications, home monitoring] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) **4. Treatment and Services the Patient is Likely to Need Including Allied Health Referrals** [summary of recommended services/referrals including service type, provider or organisation, purpose, and frequency] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in structured list format. Repeat for each referral.) (Example format for each referral/service: - **Service/Referral Type:** [service/referral type] **Provider/Organisation:** [provider/organisation] **Purpose/Details:** [reason for referral] **Frequency/Timing:** [frequency or timing]) **5. Patient Consent & Documentation** Patient has consented to the preparation of this plan and sharing with multidisciplinary team Patient / carer offered a copy of the plan Patient consented to plan being uploaded to My Health Record (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, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)