GPCCMP

**<u>GP Chronic Condition Management Plan (GPCCMP) & Reviews</u>** <u>Patient Eligibility & Consent:</u> "Patient has one or more chronic medical conditions present for ≥6 months. Verbal consent obtained to prepare a GPCCM and to share relevant information with members of the care team, where applicable. Patient agrees to the development and reviews of this plan." **<u>GP Chronic Condition Management Plan (GPCCMP):</u>** **Patient Problem or Need or Relevant Condition 1:** - Goals - Changes to be Achieved: [specific goals related to problem, need or condition 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as brief dot points.) - <u>Required Treatments and Services</u> (Including Patient Actions): [treatments, services and patient responsibilities related to problem, need or condition 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as dot points.) - Arrangements for Treatment/Services: [how treatments and services for problem, need or condition 1 will be organised] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as dot points.) **Patient Problem or Need or Relevant Condition 2:** - Goals - Changes to be Achieved: [specific goals related to problem, need or condition 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as brief dot points.) - <u>Required Treatments and Services</u> (Including Patient Actions): [treatments, services and patient responsibilities related to problem, need or condition 2] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as dot points.) - Arrangements for Treatment/Services: [how treatments and services for problem, need or condition 2 will be organised] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as dot points.) **Patient Problem or Need or Relevant Condition 3:** - Goals - Changes to be Achieved: [specific goals related to problem, need or condition 3] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as brief dot points.) - <u>Required Treatments and Services</u> (Including Patient Actions): [treatments, services and patient responsibilities related to problem, need or condition 3] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as dot points.) - Arrangements for Treatment/Services: [how treatments and services for problem, need or condition 3 will be organised] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as dot points.) (If additional problems, needs or conditions are mentioned beyond the above three, repeat the same format adding a new numbered Patient Problem or Need or Relevant Condition section for each.) Other Problems: [other problems not covered under the specific conditions above] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as brief dot points.) **<u>PATIENT ACTIONS:</u>** [key actions the patient is to take over the coming months] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as dot points. Never include actions to be taken by any health professionals.) **Service Coordination:** [other health professionals involved in this plan and a brief summary of each health professional's role in achieving the patient's goals] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else leave blank. Write as dot points, one per health professional.) "Patient given Plan & a copy saved to patient's medical record." Date Service was Completed: [today's date] (Insert today's date in DD/MM/YYYY format.) Review Date: [planned review date] (If a review date is explicitly mentioned in the transcript, contextual notes or clinical notes, use that date. If not mentioned, insert the date exactly 3 months from today in DD/MM/YYYY format.)