Proactive Primary Care Project 1

Patient Details: John Smith Date of birth / age: 12/03/1950 / 74 years Medical record number: 1234567 Contact details: 01234 567890 Date of consultation: 01 November 2024 Present: Dr. Anne Brown, General Practitioner, and John Smith, patient. 1. MyMedicare: * Patient is registered. * Discussed with patient. * No follow-up required. 2. Care Plan: * Existing care plan reviewed. * Review scheduled for 6 months. 3. Health Screening: * Patient is over 75. * DEXA scan due in 12 months. * FOBT due in 2 years. 4. Vaccinations: * Influenza vaccine administered. * Pneumococcal vaccine administered. * COVID booster due in 6 months. 5. Polypharmacy: * Home Medicine Review completed. * Report received. * No follow-up required. 6. Cardiovascular Risk (CVD): * Patient has a history of hypertension. * Blood pressure monitoring ongoing. * Review blood pressure in 3 months. 7. Falls: * Patient at moderate risk. * Referral to physiotherapy for falls assessment. * Follow up in 4 weeks. 8. Diabetes: * Patient is pre-diabetic. * HbA1c to be repeated in 3 months. * Lifestyle advice given. 9. Social Needs: * Patient requires assistance with transport. * Referral to local community transport service. * Follow up in 2 weeks. 10. Mental Health: * Patient reports mild anxiety. * Care plan review in 3 months. * Monitoring with GAD-7 questionnaire. 11. Other Issues: * Osteoarthritis in knees. * Review pain management in 6 months. Duration: 30 minutes Clinician Details: Dr. Anne Brown, General Practitioner Date of completion: 01 November 2024 Signature/electronic authentication: Electronically signed.