APC GPCCMP template

**GP Chronic Condition Management Plan (GPCCMP)** **Patient Name:** John Smith **DOB:** 12/03/1960 **Date of Plan Preparation:** 01 November 2024 **Prepared by:** Dr. Emily Carter **Review Date:** 01 May 2025 **1. Description of Chronic Conditions and Associated Health Care Needs** **Chronic Conditions:** Mr. Smith has been diagnosed with Type 2 Diabetes Mellitus in 2018. His most recent HbA1c was 7.8% (20/10/2024). He also has hypertension, diagnosed in 2015, currently managed with medication. He reports occasional chest pain, investigated in 2023 with normal findings. **Associated Health Care Needs:** * Medication management for diabetes and hypertension. * Regular blood glucose monitoring. * Annual eye exams and foot checks. * Dietary and exercise education. * Referral to a dietician. **Current Medications:** * Metformin 1000mg twice daily, started 01/01/2019. * Lisinopril 20mg once daily, started 01/01/2015. **2. Health and Lifestyle Goals (SMART Goals)** * **Clinical Area:** Diabetes Management **SMART Goal:** Reduce HbA1c to below 7.0% within six months. **Action Plan:** Continue current medication, attend all scheduled appointments, follow dietician's advice, and monitor blood glucose levels twice daily. * **Clinical Area:** Blood Pressure Management **SMART Goal:** Maintain blood pressure below 130/80 mmHg consistently. **Action Plan:** Continue Lisinopril, monitor blood pressure at home twice weekly, and attend follow-up appointments. **3. Actions to Be Taken by the Patient** * Take medications as prescribed. * Attend all scheduled appointments with GP, dietician, and ophthalmologist. * Follow a healthy diet, low in saturated fats and sugars. * Engage in regular physical activity (30 minutes of moderate-intensity exercise most days of the week). * Monitor blood glucose levels and blood pressure as instructed. **4. Treatment and Services the Patient is Likely to Need Including Allied Health Referrals** - **Service/Referral Type:** Dietician **Provider/Organisation:** Local Dietician Clinic **Purpose/Details:** Dietary advice and education for diabetes management. **Frequency/Timing:** Monthly for the first three months, then as needed. - **Service/Referral Type:** Ophthalmology **Provider/Organisation:** Local Eye Clinic **Purpose/Details:** Annual eye exam to screen for diabetic retinopathy. **Frequency/Timing:** Annually. **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