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General Practitioner Template

Care Plan Review

About this template

This Care Plan Review template is designed for General Practitioners to systematically review and update a patient's care plan. It includes sections for past medical history, medications, immunizations, allergies, and psychosocial history. The template also provides space for significant events since the last review and recommendations for ongoing care. This comprehensive format ensures that all aspects of a patient's health are considered, making it an essential tool for GPs to maintain up-to-date and effective care plans. Ideal for use with Heidi, this template streamlines documentation and enhances patient care management.

Preview template

Care Plan Review Review of care plan created by facility on 01/15/2023 Diagnoses have been reviewed and updated as appropriate. Past Medical History Date of medical history: 01/10/2023 Active medical conditions: Hypertension (diagnosed 03/2018), Type 2 Diabetes (diagnosed 06/2020) Inactive medical conditions: Asthma (resolved 05/2015) Relevant diagnostic tests or procedures: HbA1c 7.2% (01/05/2023), Blood Pressure 130/85 mmHg (01/10/2023) Advance health directive details: Patient has a living will dated 02/20/2020 Medications Current medications: Metformin 500mg twice daily, Lisinopril 10mg once daily Patient's PMC checked for up-to-date medication list Immunisation Influenza vaccine 10/2022, COVID-19 booster 11/2022 Allergies Penicillin PsychoSocial History and Functional Assessment Advance care directive status: Active COVID vaccine status: Up to date Care providers: Dr. Sarah Lee (Endocrinologist), Dr. John Smith (Cardiologist) Details of GP visits: Last visit on 01/10/2023 Significant Events Since last review: Hospital admission for chest pain on 12/15/2022, medication adjustment on 01/05/2023 Recommendations / Actions Additional recommendations to the care plan: Increase physical activity to 30 minutes daily Instructions for monitoring weight changes: Weigh weekly Record of recent weight measurements: 180 lbs on 01/10/2023 Acceptable BP range for the patient: 120-140/80-90 mmHg Instructions for monitoring blood glucose levels: Check fasting glucose daily Instructions for pain assessment and management: Use pain scale at each visit INR management instructions: Not applicable Instructions for urinalysis and interpretation: Monthly urinalysis for microalbumin Specific monitoring or considerations based on patient's condition: Monitor for signs of hypoglycemia Psychotropic medication status and review requirements: Not applicable EPC referrals: Not required at time of review Signature of the reviewing doctor: Dr. Thomas Kelly Date of review: 01/15/2023 Instructions for filing and sharing the document: File in patient's electronic health record and share with care team via secure email.

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