Generic TCA Notes (Team Care Arrangement) Item 723

TEAM CARE ARRANGEMENTS - MBS ITEM No. 723 Patient’s Name: John Smith Date of Birth: 15/06/1975 Contact Details: 123 Health Street, Wellness Suburb, 3000 Medicare or Private Health Insurance Details: Medicare No. 1234 56789 1 Details of Patient’s Usual GP: Dr. Emily Johnson Wellness Clinic, 456 Care Avenue, Health City, 3000 Details of Patient’s Carer (if applicable): Sarah Smith, spouse Date of the last Care Plan / Team Care Arrangements (if done): 01/05/2024 Other notes or comments relevant to the patient’s Team Care Arrangements: Patient requires regular monitoring of blood pressure and diabetes management. PAST MEDICAL HISTORY Hypertension, Type 2 Diabetes, Appendectomy (2010) FAMILY HISTORY Father had coronary artery disease, mother has Type 2 Diabetes MEDICATIONS Metformin 500mg, twice daily, oral Lisinopril 10mg, once daily, oral ALLERGIES Penicillin - causes rash Goals - changes to be achieved Achieve blood pressure control within normal range, maintain HbA1c below 7% Required treatments and services including patient actions Regular blood pressure monitoring, dietary modifications, exercise program Specific arrangements for treatments/services (when, who, and contact details) Dietitian appointment on 10/11/2024 with Jane Doe, contact: 9876 54321 Copy of Team Care Arrangements offered to patient? Yes Team Care Arrangements added to the patient’s records? Yes Copy / relevant parts of the Team Care Arrangements supplied to other providers? Yes Referral forms for Medicare allied health and dental care services completed? Yes Date service was completed: 01/11/2024 Proposed Review Date: 01/05/2025 "I have explained the steps and any costs involved, and the patient has agreed to proceed with the Team Care Arrangements." "The patient also agrees to the involvement of other health providers and to share their clinical information without restrictions." GP’s Signature: Dr. Emily Johnson Date: 01/11/2024