This Chronic Disease Management template, or Chronic Conditions Management template, is used by general practitioners in Australia to comprehensively document ongoing reviews for patients with chronic conditions.
Using this template with Heidi supports clinicians in generating chronic care management plans that:
- Document patient-reported symptoms, examination findings, and GPMP or TCA documentation across multiple chronic conditions.
- Identify clinical risks, complications, and social or systemic barriers affecting care plan adherence.
- Evaluate the effectiveness of current management plans and support documentation aligned with MBS chronic disease management items.
What is a Chronic Disease Management Template?
A Chronic Disease Management (CDM) Template is a structured document used by GPs and practice teams to organise and manage the ongoing care of patients with chronic conditions.
A CDM template enhances care coordination and communication between clinicians, improving treatment consistency. By tracking medications, symptoms, and interventions in a centralised document, clinicians can proactively manage chronic conditions to prevent potential complications and promote improved adherence to established care plans.
In this article, we'll discuss the key components of an effective chronic disease management plan template, share a step-by-step guide on how you can write and use a CDM template to improve patient outcomes, and provide you with customisable, AI-enabled CDM templates you can use in your general practice.
The State of Chronic Conditions Management in Australia
Managing chronic conditions is the centre of general practice in Australia. Around half of Australia live with a chronic condition, 38% live with two or more, and chronic conditions now contribute to about 90% of deaths.
In the consulting room, the concentration is starker still: more than half of patients at GP encounters have two or more chronic conditions, and multimorbidity rises with age until it reaches nearly four in five people over 85.
Caring for these patients means tracking multiple medications, coordinating with specialists, and allied health professionals. It also means keeping the clinical record consistent as the picture changes over months and years. That’s why the system itself changed.
GP Chronic Condition Management Plans
Since July 2025, the older GP Management Plan and Team Care Arrangements have been replaced by a single GP Chronic Condition Management Plan, designed to reduce paperwork and strengthen continuity of care through MyMedicare.
Structure alone does not guarantee results. Australian research on care planning is blunt about it: plans are intended to deliver evidence-based, coordinated care, but recommended care is not always delivered and outcomes are often not achieved.
A plan is only as good as how well it is maintained and reviewed. The real work of chronic conditions management is keeping that plan straight, visit after visit, so the documentation reflects the care as it actually happens.
Key Components of an Effective Chronic Disease Management Template
An effective chronic disease management documentation template must comprehensively capture the following key elements:
Patient Information
Basic details, including the patient's name, age, and medical history, along with the specific reason for their visit.
Diagnosis and Chronic Conditions
A detailed overview listing each of the patient's chronic conditions alongside reported symptoms and severity.
Medications and Allergies
An outline of the patient's allergies and current medications, including dosages and adherence. Note whether medications are effectively controlling symptoms.
Care Goals and Treatment Plan
SMART targets that align with the patient's condition: Specific, Measurable, Achievable, Relevant and Time-Bound. Changes in medication, diet, or activity should also be documented.
Interventions and Action Steps
The specific steps the GP or clinician will take to address the patient's condition, including the patient's self-management responsibilities such as prescribed lifestyle changes around diet and exercise. Emergency actions in case symptoms worsen are also outlined here.
Follow-Up Schedule and Coordination Notes
A record of future visits and any referrals necessary for continuity of care, including allied health referrals under a TCA. This section also captures information to be shared with the broader care team: recent lab results, care plan review scheduling under MBS item 732, and instructions for the patient's self-care.
Dr. Gihan de Mel, a physiotherapist based in Melbourne, Australia, saves 1 to 2 hours every day on notes.
With a busy clinic and a growing business, documentation was cutting into both. "For me, there are only a few things in physio that I would call a game changer, and using Heidi has definitely been one of them."
Less time on notes means less mental fatigue at the end of a long day. He gets home earlier, has more energy for his clinical work, and has room to grow his practice without sacrificing patient time.
How to Write and Use a CDM Template to Improve Patient Outcomes
This guide walks you through the process of writing and using a CDM template effectively, so you get a better understanding of how the key components discussed previously are put into practice.
1. Start with a Clear Patient Overview
Summarise the patient's current status, including medical history relevant to their condition and the chronic conditions themselves. Document the primary reason for their visit to provide context and ensure focused care.
Sample Notes: Jack Marston (67M) attends for routine 6/12 Chronic Disease Management (CDM) review. PMHx includes HTN, T2DM, and CKD. Sees a podiatrist and diabetes educator under his Team Care Arrangement; results available on My Health Record.
2. Document Patient-Reported Symptoms and Concerns
Write down patient-reported symptoms clearly and accurately, and note whether symptoms are improving, worsening or stable.
Sample Notes: Patient reports mild HAs a couple of days a week. Nil red flags (nil visual disturbances or dizziness). Symptom frequency correlates strongly with stress levels. Currently managing well with OTC Panadol/Nurofen PRN. Advised to monitor frequency; discussed potential Psychology referral via MHTP if stress triggers worsen.
3. Set Individualised Care Goals
Tailor goals to the patient's condition and capabilities. Set SMART targets the patient can realistically achieve to maintain motivation throughout the care plan. Include both short-term and long-term goals to sustain engagement and improve health outcomes.
Sample Notes: Aim HbA1c < 7.0% within 3 months via med titration and TCA referral to dietitian. Target BP < 130/80 within a fortnight and maintain stability for 6-monthly GPMP R/V.
4. Create an Actionable Treatment and Follow-Up Plan
Outline specific care and self-management tasks for the GP, clinician and patient. Define milestones to make progress assessment easier and identify any need to adjust the care plan. Ensure the patient understands and supports the plan fully.
Sample Notes: GP to review and adjust perindopril dosage based on patient's home BP trends. Patient to monitor BP BD and document in a BP diary, to be reviewed at their upcoming 3/12 GPMP/TCA review. Written instructions provided for dosing schedule.
5. Coordinate Care Across the Team
Share care plan details with specialists and allied health providers coordinated under a TCA to align treatment strategies. Use a centralised documentation tool such as an electronic health record to keep all care team members updated.
Sample Notes: Updated TCA forwarded to treating Endocrinologist outlining recent OHG adjustments (dose increased to MANE and NOCTE). Local clinical software and My Health Record updated with latest pathology results and current medication summary.
6. Educate and Empower Your Patient
Provide clear instructions for self-care and medication use, and involve patients in tracking progress against short- and long-term goals. Identify potential barriers to care plan adherence and provide support where possible.
Sample Notes: Patient educated on dietary sodium restriction and HBPM protocols. Advised to log BGLs DAILY and notify clinic of any unexpected spikes. Assessed financial barriers to compliance; explored PBS entitlements and concession card options. Compliance and logs to be assessed at next GPMP R/V.
7. Monitor Progress and Adjust as Needed
Review the care plan's effectiveness at each chronic disease review and document specific changes and reasons for adjustment. Track long-term progress to identify trends and improve overall care quality.
Sample Notes: Medication titrated to a higher dose (taken MANE) due to refractory HTN despite active lifestyle interventions. Will arrange further investigations (e.g., 24hr ambulatory BP monitoring) if targets are not met by next TCA R/V. Glycaemic control remains excellent; HbA1c stable at 6.8% across the last three routine reviews.
Creating, managing, and implementing chronic disease management plans is a demanding and time-consuming task that adds to the already significant workload of GPs and practice teams.
AI-powered tools can now help streamline CDM plan documentation, reducing the administrative burden without compromising documentation quality.
Complete Chronic Disease Management Templates Faster with Heidi
GPs spend significant time on CDM documentation. Heidi, your AI Care Partner, handles that work 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:
- Transcribe - Heidi transcribes your conversation in the background as you speak with your patient, gather information for the care plan, and walk them through the plan to be implemented. Any specific details you prefer not to verbalise can be added later under the context tab.
- Customise - After the session, select your preferred CDM template and Heidi populates the documentation with the details of your conversation and context notes in the appropriate format.
- Transform -Once your CDM plan is generated, ask Heidi for additional documentation, including medication instructions and care plan review reminders as needed.
Heidi complies with Australian privacy law, including the Australian Privacy Principles (APP), with data localisation for Australian customers. Since launch, clinicians across Australia has completed 46 million patient interactions and saved 19.2 million hours on documentation.
Free Customisable Chronic Disease Management Templates
