TCA Notes for Depression and Anxiety Disorders

Patient’s Name: John Smith Date of Birth: 15/06/1985 Contact Details: 123 Main Street, Suburbia, 12345 Medicare or Private Health Insurance Details: Medicare No. 1234 56789 1 Details of Patient’s Usual GP: Dr. Emily Johnson Suburbia Health Clinic, 456 Health Ave, Suburbia, 12345 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 has shown improvement in managing anxiety symptoms with current treatment plan. PAST MEDICAL HISTORY - Hypertension - Type 2 Diabetes - Appendectomy in 2010 FAMILY HISTORY - Father with history of depression - Mother with hypertension MEDICATIONS - Metformin 500mg, twice daily, oral - Lisinopril 10mg, once daily, oral - Sertraline 50mg, once daily, oral ALLERGIES - Penicillin: rash TEAM CARE ARRANGEMENTS - MBS ITEM No. 723 (DEPRESSION/ANXIETY DISORDER) **Goals - changes to be achieved** - Patient to have a clear understanding of depression/anxiety and how it can be managed through educational sessions with GP and psychologist. - Decrease severity and frequency of symptoms of depression/anxiety through regular therapy sessions and medication adjustments. - Identify stressors and precipitants through cognitive behavioral therapy (CBT). - Avoid relapse by maintaining regular follow-ups and support group participation. - Maintain healthy diet and optimum weight range with dietitian consultations. - Maintain physical activity through a personalized exercise program. - Medication management with regular reviews by GP. - Improve social and family functioning through family therapy sessions. **Required treatments and services including patient actions** - Patient education by GP and psychologist. - Medication management by GP. - Consider: CBT, counseling, and relaxation training. - Address stressors and known risk factors through counseling and CBT. - Smoking cessation with referral to Quit program. - Control alcohol/substance abuse with support group involvement. - Stress management through support groups and counseling. **Specific arrangements for treatments/services (when, who, and contact details)** - Patient education re healthy nutrition and weight control by dietitian, Dr. Emily Johnson. - Establishment of exercise program by exercise physiologist, John Doe. - Smoking cessation program by Quit program professionals. - Management of alcohol/substance abuse by counselor, Jane Doe. - Ensure correct use of medications with Home Medicine Review by pharmacist, Dr. Emily Johnson. - Support group involvement facilitated by counselor, Jane Doe. 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