HSMC.GPCCMP Review

**GP Chronic Condition Management Plan (GPCCMP) Review Details:** **1. Review of Overall Progress and Goals:** - **Patient's Progress Towards Goals:** [Document the patient’s progress in relation to the goals outlined in the original GPCCMP. Capture discussions about what has been achieved or where challenges remain, and whether the goals remain appropriate for their current health status.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Updates to GPCCMP (Goals, Actions, Services):** [State whether any updates or amendments were made to the GPCCMP during the consult. If yes, specify the changes to goals, patient actions, or required treatments/services. This includes any new or modified goals, patient responsibilities, or care plans.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **2. Updated Multidisciplinary Care Assessment & Referrals:**(Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Consideration of Multidisciplinary Team Information (if any):** [Document if information provided by members of the multidisciplinary team (if any, e.g., specialist reports, allied health notes) was discussed and considered in relation to their treatment of the patient and the extent to which their services are supporting the patient to meet the patient’s goals.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **New/Updated Referrals and Consent to Share:** [If new referrals are made or existing ones updated, document the patient’s explicit consent to sharing relevant updated parts of the plan with members of the multidisciplinary team. List specific services referred to or updated, including their purpose.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Provision of Updated Plan to MDT:** [Confirm that relevant updated parts of the plan will be provided to the members of the multidisciplinary team, if the patient has consented.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **3. Updated Preventative Health & Lifestyle:**(Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Immunisations Action:** [Document any new vaccine recommendations or status updates discussed during the review (Flu, COVID-19, Pneumonia, Other).] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Smoking Status & Action:** [If smoking status was a focus of review or has changed, capture current status and any updated advice/support.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Alcohol Use & Action:** [If alcohol use was a focus of review or has changed, capture current use and any updated advice.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Exercise Habits & Action:** [If exercise was a focus of review or has changed, capture current habits and any updated advice/goals.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Diet Habits & Action:** [If diet was a focus of review or has changed, capture current diet and any updated advice/goals.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Screening Tests (CST, FOBT, Mammogram, Pathology):** [Document any updates to screening test dates (last/next due) if discussed during the review. ONLY include if relevant (patient age/gender criteria still apply, as per original plan).] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Advanced Care Directive:** [Document if there's any update to the patient's Advanced Care Directive status or location.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Home Medicine Review (HMR):** [Document if an HMR was discussed or agreed upon during this review.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **4. Arrangements to Review the Plan:** - **Updated Review Arrangements:** [Confirm that the arrangements to review the plan have been updated, including the proposed timeframe for the next review and whether it will be with nurse or general practitioner, and any other required updates made in consultation with the patient. This should be explicitly discussed (e.g., "Next review scheduled for [Date], approximately 3 months").] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **GPCCMP Review Process Documentation:** - **Patient Consent and Agreement to Updates:** [Document clear verbal confirmation of the patient's consent and agreement to the updates made to the GPCCMP during the review. (e.g., "Patient verbally consented to the plan updates and revised goals.")] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Offer of Updated Plan Copy to Patient/Carer:** [Document that a copy of the updated plan was offered to the patient. If applicable, also document if a copy was offered to the patient’s carer (if any, if considered appropriate, and if patient agreed) and whether they accepted. (e.g., "Copy of updated plan offered to patient and accepted." or "Copy offered to patient and declined." or "Copy offered to patient and carer [Carer's Name] and accepted.")] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Updated Plan Added to Medical Records:** [Confirm that a copy of the updated plan will be added to the patient's medical records. (e.g., "Updated plan to be uploaded to patient's medical records.")] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Medicare Item Number & Recall:** - **Medicare Item Number:** [State the appropriate Medicare item number for this GPCCMP review (the new item numbers post-July 2025).] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - 3**/12 Recall:** [Confirm if a 3-month recall was entered into the recall system for the next review or discussed.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - **Follow-up Appointment with Nurse:** [Confirm if a follow-up appointment with the practice nurse has been made or recommended, or if this action was discussed.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)