Dictate anywhere on your screen, capture telehealth audio straight from the call,
and skip the second login.
Shine Colcol
Fact checked by Dr. Ben Condon
This detailed, AI-enabled GPMP notes template (Item 721) guides General Practitioners in creating structured GP management plans for patients with chronic conditions, based on the most recent Australian government guidance.
Important Note: The GPMP has changed. From July 2025, the GPMP and TCA became one plan, the GPCCMP. Your existing GPMP is still valid until 30 June 2027.
A GP Management Plan (GPMP, item 721) was the Medicare-funded plan for chronic or complex conditions. Since 1 July 2025, it has been replaced by the GPCCMP. The GPCCMP applies to any patient with a condition lasting, or likely to last, six months or more, or that is terminal.
Under the old system, a GPMP was often paired with a TCA (item 723) for patients needing other providers. The GPCCMP removes that split: it is a single plan, and the requirement to formally involve two other providers has been dropped.
In this article, we'll discuss the importance of GPMP review templates, what changed under the new GPCCMP framework, and best practices for creating GP management plans. We'll also share free, customisable, AI-enabled GPCCMP templates you can use in your practice.
GP management plan templates ensure complex care plans are well-organised and easy to follow. They help GPs save time, reduce errors and improve communication across care teams. A well-structured GPMP template supports better patient outcomes through efficient and coordinated care.
For years, the decision was which plan to write: a GPMP for care led by a single GP or a TCA when the patient needed a team around them. That choice is gone. Now, there’s one plan: the GPCCMP.
Here’s a quick breakdown of the updates on the template:
| What changed | Old system (GPMP + TCA) | New system (GPCCMP) |
|---|---|---|
| The plan | Two documents: a GPMP (item 721) and, for team care, a separate TCA (item 723) | A single plan, the GPCCMP, for every eligible patient |
| MBS fee | Higher to prepare, lower to review | Equalised for preparation and review, about $156.55 for GPs or $125.30 for PMPs |
| Team involvement | A TCA required formal input from at least two other providers | No two-provider requirement; the GP coordinates care directly |
| Referrals | A structured Medicare (EPC) referral form | A standard referral letter, valid for 18 months |
| Reviews | Reviewed under a separate item, worth less than a new plan | Reviewed under the GPCCMP at the same rebate as preparation, so regular 3-monthly reviews are worthwhile |
| Allied health | Up to 5 subsidised services a year (10 for Aboriginal and Torres Strait Islander patients) | Unchanged: up to 5 a year (10 for Aboriginal and Torres Strait Islander patients) |
| Continuity | Patients could move between clinics for planning | Linked to the patient's MyMedicare-registered practice |
For many clinicians, documentation is more than an administrative task. It drains energy, limits capacity, and pulls attention away from patients. For clinicians with dyslexia, these challenges often run deeper.
AI tools level the playing field when they support how clinicians naturally work. Instead of forcing documentation through typing alone, they let clinicians capture their thinking through speech. This reduces cognitive load while preserving clinical quality.
Dr Lisa Gibson, is a registered psychologist with dyslexia based in New Zealand. By leveraging Heidi, she saves 2.5 hours daily by using the voice-to-text features.
As she put it, “When I can use Heidi or even summarise a session verbally to Heidi, it plays to my strengths, which safeguards my capacity and my energy, which means I can do more of the things that I love.”
Following best practices ensures that GPMPs are accurate, comprehensive, and effective tools for chronic disease management (CDM). Read through our key tips below for creating clear and efficient GPMPs for high-quality patient care:
Cover the patient’s full details, including their name, date of birth, Medicare number, and contact information. Record the date of the current GPMP and any previous GPMPs completed for tracking purposes. Finally, specify the GP’s details, including their full name, qualifications, and contact information for accountability and easy follow-ups.
Document the patient’s medical history, including past surgeries, hospitalisations, and chronic conditions. Log their current medications and known allergies to avoid potential drug interactions and adverse reactions, then list relevant immunisation status to inform preventive care.
Define specific health goals e.g., “Achieve and maintain blood pressure below 130/80 mmHg”, and align them with the patient’s overall health status and long-term wellbeing. Ensure that goals are SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) so progress is easily tracked.
Detail the agreed actions and coverage of each party, e.g., the GP, the patient, and other health care professionals. Assign responsibilities to specific professionals as well as the patient, e.g., “Dietitian to advise on sodium reduction”, “Patient to do 30 minutes of brisk walking 5 days a week.”
Set a review date for assessing progress and adjust the management plan as needed. Include regular check-ups for relevant tests e.g., “Kidney function tests every 6 months,” and schedule medication reviews and mental health screenings if deemed necessary.
Confirming the patient’s understanding and agreement with the management plan through signatures is crucial for getting them to cooperate. Provide them with educational materials, such as online resources, and ask for their feedback to encourage their continued participation.
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
Here’s a free GP management plan template example in PDF and Google Doc form.
GP management plan templates are often completed manually on paper or via electronic forms through data entry. While they get the job done in most cases, this “traditional” method doesn’t prevent input errors and missing information.
Thankfully, an AI-powered solution now offers a faster and more accurate way to create GPCCMP plans, helping healthcare providers streamline their documentation process.
Heidi, your AI care partner, helps you document GPCCMP in real-time so you can stay focused on the patient in front of you.
With your patient's permission, start a session and let Heidi transcribe as you go. Here's how it works:
Heidi supports over 751,000 patient interactions every week in Australia, with data stored locally and in compliance with the Australian Privacy Principles.
This narrative-style GPMP Notes template is a comprehensive tool designed to document care plans effectively. It is based on the latest guidance by the Australian Government and captures key details such as patient information, medical history, current health needs, and health management goals.
This template is designed to guide GPs in creating simple GPMPs for patients with chronic conditions. It documents essential info such as patient information, medical history, current medications, and management goals. It also outlines the required treatments and services, ensuring a structured approach to patient care.
This template helps GPs document relevant patient information when creating care plans for chronic conditions. It covers essential details including the patient’s medical history, current medications, as well as agreed actions by health professionals and patients related to quality of life, monitoring of health conditions, mental health and wellbeing.
Since July 2025, the GPMP and TCA have been combined into one plan. After the update, it was replaced by the GPCCMP, which covers a patient’s individual care plan and coordinates input from multiple providers when needed in a single document.
| Eligibility | A condition lasting, or likely to last, 6 months or more | Unchanged: a condition lasting or likely to last 6 months or more, or terminal, with no fixed list of conditions |
