General Practitioner Template

GP chronic condition management plan

A professional General Practitioner template for healthcare professionals.

About this template

Need a clear and concise plan for managing chronic conditions? A GP chronic condition management plan template is a vital tool for General Practitioners. This template helps GPs document and track patient goals, tasks, and reviews for conditions like diabetes, hypertension, and arthritis. It ensures a structured approach to patient care, including SMART goals, patient and GP responsibilities, and multidisciplinary team involvement. This template is designed to be used with medical AI scribe software like Heidi, streamlining the documentation process and improving patient outcomes.

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Conditions: * Type 2 Diabetes Mellitus * Hypertension * Osteoarthritis SMART Goals: * Diabetes: Patient will reduce HbA1c to below 7.0% within 6 months through diet and exercise, monitored at 3-monthly reviews. (Specific, Measurable, Achievable, Relevant, Time-bound) * Hypertension: Patient will achieve a blood pressure reading of less than 130/80 mmHg within 3 months through medication and lifestyle changes, reviewed monthly. (Specific, Measurable, Achievable, Relevant, Time-bound) * Osteoarthritis: Patient will increase mobility and reduce pain levels to a score of less than 4/10 on the visual analogue scale (VAS) within 6 weeks through physiotherapy and pain management, reviewed at 6-weekly intervals. (Specific, Measurable, Achievable, Relevant, Time-bound) Tasks – Patient: * Diabetes: Follow a structured meal plan, engage in 30 minutes of moderate-intensity exercise most days of the week, and monitor blood glucose levels daily. * Hypertension: Take prescribed medication as directed, monitor blood pressure at home twice weekly, and reduce sodium intake. * Osteoarthritis: Attend physiotherapy sessions twice a week, perform prescribed exercises daily, and take paracetamol as needed for pain relief. Tasks – GP: * Diabetes: Review blood glucose control, medication adherence, and adjust medications as needed. Order HbA1c and renal function tests every 3 months. * Hypertension: Review blood pressure readings, medication efficacy, and adjust medications as needed. Order blood tests to monitor kidney function and electrolytes every 6 months. * Osteoarthritis: Review pain levels, mobility, and medication effectiveness. Consider referral to an orthopaedic specialist if symptoms worsen. Tasks – Practice Nurse: * Diabetes: Provide education on diabetes self-management, including diet, exercise, and medication. Administer annual flu and pneumococcal vaccinations. * Hypertension: Monitor blood pressure and provide lifestyle advice. Review medication side effects and adherence. * Osteoarthritis: Provide education on pain management strategies and exercise. Offer advice on assistive devices. Tasks – Multidisciplinary Team Members: * Dietitian: * Provide a structured meal plan tailored to the patient's diabetes and hypertension. * Educate the patient on carbohydrate counting and portion control. * Review dietary intake and provide feedback every 3 months. * Clinical rationale: Optimise blood glucose control and blood pressure management through dietary modifications. * Frequency of reviews: Every 3 months. * Reporting outcomes: Report HbA1c, blood pressure, and dietary adherence to the GP. * Physiotherapist: * Assess the patient's mobility and pain levels. * Develop an exercise program to improve joint function and reduce pain. * Provide education on proper posture and body mechanics. * Clinical rationale: Improve mobility and reduce pain associated with osteoarthritis. * Frequency of reviews: Every 6 weeks. * Reporting outcomes: Report pain scores, mobility improvements, and exercise adherence to the GP. Review Plan: * Review every 3 months by Dr. Thomas Kelly. Activities include medication review, blood test review, and goal setting. "Patient verbally consented to audio transcription and is aware that: - Audio recording would be completed during the consultation - Recording is for the purpose of creating notes"

Conditions: [list of chronic health conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Provide a succinct bullet-point list summarising each chronic condition.) SMART Goals: [goals specific to each condition, aligned with patient lifestyle and preferences] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write specific, measurable, achievable, relevant, and time-bound goals. Use shared decision-making. Write in bullet point format.) Tasks – Patient: [actions for the patient to take related to lifestyle, self-management and follow-up] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points. Include lifestyle changes, home monitoring, adherence strategies, and attendance at scheduled reviews.) Tasks – GP: [responsibilities assigned to the GP] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points. Include medication reviews, diagnostic monitoring, care coordination, referrals and plan updates.) Tasks – Practice Nurse: [practice nurse responsibilities in ongoing care] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points. Include BP/BMI monitoring, anticipatory care planning, patient education, and immunisation review and administration.) Tasks – Multidisciplinary Team Members: [referrals and responsibilities for allied health professionals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. For each referred team member such as Dietitian, Podiatrist, Diabetes Educator etc, include: - 3–4 specific tasks they are expected to perform - Clinical rationale for their involvement - Recommended frequency of reviews - Clear plan for reporting outcomes back to the GP. Write as bullet points under each professional’s heading.) Review Plan: [review schedule and responsible clinician] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Recommend a structured GP Chronic Care Management Plan review every 3 months unless otherwise clinically justified. Include the timeframe, responsible clinician, and any planned activities during the review.) "Patient verbally consented to audio transcription and is aware that: - Audio recording would be completed during the consultation - Recording is for the purpose of creating notes" (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 bullet points or paragraphs as needed to capture all the relevant information from the transcript.)

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Specialty

General Practitioner

Used

10 times

Type

Note

Last edited

11/18/2025

Created by

Deb Babatunde

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