GP Chronic Condition Management Plan (GPCCMP)
(MBS Items 965 – Initial / 967 – Review)
Patient Eligibility
Patient has one or more chronic medical conditions present for ≥6 months:
Diabetes Mellitus Type 2, Hypertension
Patient Consent
Verbal consent obtained to prepare a GP Chronic Condition Management Plan and to share relevant information with members of the care team, where applicable.
Patient agrees to the development (or review) of this plan.
GP Chronic Condition Management Plan (GPCCMP):
Patient Problem or Need or Relevant Condition 1:
- Goals – Changes to be Achieved: Improved blood glucose control, blood pressure within target range.
- Required Treatments and Services (Including Patient Actions): Regular blood glucose monitoring, medication adherence (Metformin, Lisinopril), healthy diet, regular exercise, annual diabetic eye exam, foot check, and kidney function tests.
- Arrangements for Treatment/Services: Patient to attend diabetes education sessions, follow-up appointments with GP every 3 months, referral to a dietician.
Patient Problem or Need or Relevant Condition 2:
- Goals – Changes to be Achieved: Reduce blood pressure to below 140/90 mmHg.
- Required Treatments and Services (Including Patient Actions): Medication adherence (Lisinopril), regular blood pressure monitoring at home, reduce sodium intake, regular exercise.
- Arrangements for Treatment/Services: Follow-up appointments with GP every 3 months, referral to a cardiologist if blood pressure remains uncontrolled.
Other Problems:
Patient reports mild anxiety related to managing their chronic conditions.
Service Coordination / Follow-up
- Coordination tasks completed: eReferral sent to a dietician, My Health Record updated.
- Relevant parts of the plan shared with providers (if patient consented) Yes, with the dietician and cardiologist.
Review Arrangements
Plan will be reviewed on or before: 1 May 2025
Progress toward goals and treatment response to be evaluated at that time.
Adjustments will be made in collaboration with patient and care team as needed.
Plan Distribution and Storage
Patient was offered a copy of the plan (and to carer, if applicable):
– accepted
A copy of the plan has been saved to the patient’s medical record.
Date Service was Completed:
1 November 2024
Review Date:
1 May 2025
GP Chronic Condition Management Plan (GPCCMP)
(MBS Items 965 – Initial / 967 – Review)
Patient Eligibility
Patient has one or more chronic medical conditions present for ≥6 months:
[chronic condition(s)] (Insert one or more chronic conditions that have been present for six months or longer. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Patient Consent
Verbal consent obtained to prepare a GP Chronic Condition Management Plan and to share relevant information with members of the care team, where applicable.
Patient agrees to the development (or review) of this plan.
GP Chronic Condition Management Plan (GPCCMP):
Patient Problem or Need or Relevant Condition 1:
- Goals – Changes to be Achieved: [goals related to condition 1] (Describe the specific health goals or behaviour changes the patient is working toward. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Required Treatments and Services (Including Patient Actions): [treatments/services for condition 1] (List treatment modalities, referrals, self-management tasks or lifestyle interventions. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Arrangements for Treatment/Services: [arrangements for condition 1] (Explain how services will be provided or coordinated, including timing or location. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Patient Problem or Need or Relevant Condition 2:
- Goals – Changes to be Achieved: [goals related to condition 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Required Treatments and Services (Including Patient Actions): [treatments/services for condition 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Arrangements for Treatment/Services: [arrangements for condition 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Patient Problem or Need or Relevant Condition 3:
- Goals – Changes to be Achieved: [goals related to condition 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Required Treatments and Services (Including Patient Actions): [treatments/services for condition 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Arrangements for Treatment/Services: [arrangements for condition 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(using the above format, add additional problems/needs/conditions as required)
Other Problems:
[other relevant problems] (Insert other relevant clinical issues not captured under the structured condition entries above. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Service Coordination / Follow-up
- Coordination tasks completed: [coordination actions] (E.g. eReferral sent, My Health Record updated, appointment arranged. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Relevant parts of the plan shared with providers (if patient consented) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Review Arrangements
Plan will be reviewed on or before: [review date] (Insert a future date within 6 months for review. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Progress toward goals and treatment response to be evaluated at that time.
Adjustments will be made in collaboration with patient and care team as needed.
Plan Distribution and Storage
Patient was offered a copy of the plan (and to carer, if applicable):
– [accepted / declined] (State whether the patient or carer accepted or declined the copy. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
A copy of the plan has been saved to the patient’s medical record.
Date Service was Completed:
[date completed] (Insert today’s date or the date service was completed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Review Date:
[planned review date] (Insert the agreed review date, typically within 6 months. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that the information has not been explicitly mentioned in your output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs or bullet points as needed to capture all relevant information from the transcript.)
