TCA Notes for Depression and Anxiety Disorders

Patient’s Name: [Enter patient’s full legal name as recorded in medical records.] Date of Birth: [Enter patient’s date of birth in DD/MM/YYYY format.] Contact Details: [Enter patient’s full address, including street, suburb, and postcode.] Medicare or Private Health Insurance Details: [Enter patient’s Medicare number with reference number or private health insurance details.] Details of Patient’s Usual GP: [Enter the full name of the patient’s regular general practitioner.] [Enter the GP’s clinic name and full address.] Details of Patient’s Carer (if applicable): [Enter the full name and relationship of the patient’s carer if applicable. If no carer, omit this section.] Date of the last Care Plan / Team Care Arrangements (if done): [Enter the date of the last completed care plan or team care arrangement in DD/MM/YYYY format. If none, enter "Not applicable."] Other notes or comments relevant to the patient’s Team Care Arrangements: [Include any relevant clinical, administrative, or social notes related to the patient’s team care arrangement.] PAST MEDICAL HISTORY [List all significant past medical conditions, chronic illnesses, previous surgeries, and relevant medical history in a concise format.] FAMILY HISTORY [Provide details of family history related to hereditary or significant medical conditions that may impact the patient’s care.] MEDICATIONS [List all current medications, including name, dosage, frequency, and route of administration.] ALLERGIES [Specify any known allergies, including drug, food, or environmental allergens, along with the type of reaction experienced.] TEAM CARE ARRANGEMENTS - MBS ITEM No. 723 (DEPRESSION/ANXIETY DISORDER) **Goals - changes to be achieved** [Describe the specific health goals the patient is expected to achieve, including short-term and long-term objectives.] Patient to have a clear understanding of depression/anxiety and how it can be managed. [Describe educational strategies to inform the patient about their condition, treatment options, and self-management techniques.] Decrease severity and frequency of symptoms of depression/anxiety. [Describe interventions aimed at reducing symptom severity and improving patient well-being.] Identify stressors and precipitants. [Describe methods to identify and manage stressors contributing to depression or anxiety.] Avoid relapse. [List interventions focused on long-term management and relapse prevention.] Maintain healthy diet and optimum weight range. [Describe strategies for improving nutrition, weight control, and overall physical health.] Maintain physical activity. [Describe plans for increasing physical activity and setting achievable exercise goals.] Medication management. [Describe plans to ensure correct medication use and compliance.] Improve social and family functioning. [Describe strategies to improve interpersonal relationships and overall social well-being.] **Required treatments and services including patient actions** [List all recommended treatments, services, and required patient actions. Ensure the list includes medical interventions, lifestyle modifications, and therapy sessions if relevant.] Patient education [List healthcare providers involved in patient education, including GP, allied health professionals, or psychiatrists.] Medication [List any prescribed medications and dosage, along with responsible healthcare provider oversight.] Consider: [List specific treatment modalities recommended, including cognitive behavioral therapy (CBT), counseling, psychotherapy, or relaxation training.] Address stressors and known risk factors. [Provide details on strategies such as counseling, problem-solving, CBT, interpersonal therapy, family therapy, or loss/grief counseling.] Smoking cessation. [Describe smoking cessation strategies and referrals to appropriate programs.] Control alcohol/substance abuse. [Describe strategies for managing substance use and addiction.] Stress management. [Provide details on stress management techniques, support groups, or counseling programs.] **Specific arrangements for treatments/services (when, who, and contact details)** [Provide details of scheduled appointments, healthcare providers involved, contact details, and any specific arrangements for ongoing treatments.] Patient education re healthy nutrition and weight control. [List healthcare providers involved, including GP, practice nurse, or dietitian.] Establishment of exercise program. [List involved providers, such as GP, patient, or exercise physiologist.] Smoking cessation program. [List healthcare providers involved, such as GP or Quit program professionals.] Management of alcohol/substance abuse. [List support programs and involved healthcare professionals, including GP, counselor, or allied health professionals.] Ensure correct use of medications. Undertake Home Medicine Review. [List healthcare providers involved, including GP or pharmacist.] Support group. [List healthcare providers involved, including GP, counselor, or allied health professionals.] Copy of Team Care Arrangements offered to patient? [Enter "Yes" if a copy was provided to the patient; otherwise, enter "No."] Team Care Arrangements added to the patient’s records? [Enter "Yes" if the TCA was recorded in the patient’s file; otherwise, enter "No."] Copy / relevant parts of the Team Care Arrangements supplied to other providers? [Enter "Yes" if copies were sent to relevant healthcare providers; otherwise, enter "No."] Referral forms for Medicare allied health and dental care services completed? [Enter "Yes" if applicable referral forms were completed; otherwise, enter "No."] Date service was completed: [Enter the date the TCA service was finalized in DD/MM/YYYY format.] Proposed Review Date: [Enter the scheduled review date for the TCA, typically six months from completion.] "I have explained the steps and any costs involved, and the patient has agreed to proceed with the Team Care Arrangements." [Include statement if the patient consented; otherwise, do not include and state reason why based on transcript, context, clinical notes] "The patient also agrees to the involvement of other health providers and to share their clinical information [specify if with or without restrictions]." [Include statement if the patient consented; otherwise, do not include and state reason why based on transcript, context, clinical notes] GP’s Signature: [Enter GP’s full name.] Date: [Enter the date the GP signed the document in DD/MM/YYYY format.] (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 to include 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 that 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.)