GPCCMP - July 2025

Chronic Condition Management Plan / Review Patient Progress: [Describe patient's progress since the last review, including improvements, setbacks, and adherence to the care plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. Write in paragraphs using full sentences.) [Condition Name (in lay and medical terms e.g. high blood pressure (hypertension))]: Goals: [State specific SMART goals for this condition] (If not mentioned in transcript, contextual notes or clinical note, write relevant general SMART goals for this condition.) Management Arrangements: [Document arrangements between patient and doctor to manage this condition, including medications, monitoring, lifestyle changes, referrals, etc.] (If not mentioned in transcript, contextual notes or clinical note, write relevant standard arrangements for this condition.) [Condition Name (in lay and medical terms)]: Goals: [State specific SMART goals for this condition] (If not mentioned in transcript, contextual notes or clinical note, write relevant general SMART goals for this condition.) Management Arrangements: [Document arrangements between patient and doctor to manage this condition, including medications, monitoring, lifestyle changes, referrals, etc.] (If not mentioned in transcript, contextual notes or clinical note, write relevant standard arrangements for this condition.) (New Issues or Concerns) [List any new issues or concerns raised by the patient or identified during the review] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. Write in full sentences.) Weight / Lifestyle: - Goal: Maintain a healthy weight range - Optimise nutrition, physical activity, and sleep (Only include this section if lifestyle or weight is explicitly mentioned in the transcript, contextual notes or clinical note.) Mental Health: - Goal: Maintain good mental health - Regular checks as needed (Only include this section if mental health is explicitly mentioned in the transcript, contextual notes or clinical note.) Vaccination: - Goal: Ensure vaccinations are up to date (e.g. flu, COVID-19, tetanus) Bone Health: [Include comments on DEXA scans, calcium/vitamin D supplementation, resistance exercise] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. Write in full sentences.) Other Preventative Health: [Include any additional preventative health topics discussed, such as cancer screening, smoking cessation, alcohol intake, skin checks etc.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note.) Summary of Goals and Objectives: [List the overall summary of goals and objectives for the next review period in non-medical terms, including general health maintenance and screening] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. Otherwise include relevant default objectives such as: "Maintain overall health, keep up with regular check-ups, get annual flu shots, improve strength and balance with regular exercise, take medications as prescribed.") Team Care Arrangements (TCA): - [Health professional – Role] – [Review date if mentioned, otherwise "as planned"] - [Health professional – Role] – [Review date if mentioned, otherwise "as planned"] (Only include if other providers are involved in the patient's care. List in bullet points.) Next Review: [Specify the date for the next care plan review] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. If not stated, write “Review in 6–12 months or earlier as needed.”) (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 section blank.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)