Author: Toni Rice
Last saved by: tonir
Company: Microsoft

<<Miscellaneous:Practice Letterhead>>

GP MANAGEMENT PLAN - MBS ITEM No. 721 (DIABETES)

Patient’s Name: 
<<Patient Demographics:Full Name>>

Date of Birth: 
<<Patient Demographics:DOB>>

Contact Details: | Medicare or Private Health Insurance Details:

<<Patient Demographics:Full Address>>

<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>

Details of Doctor:
(Patients usual Doctor or another Doctor in the practice)

Details of Patient’s Carer (if applicable):

<<Doctor:Name>>
<<Doctor:Full Address>>

Date of last Care Plan/GP Management Plan:  
<<Date of last Care Plan/GPMP>>

Other notes or comments relevant to the patient’s management: 

PAST MEDICAL HISTORY

FAMILY HISTORY

<<Clinical Details:Family History>>

SOCIAL HISTORY

<<Clinical Details:Social History>>

OCCUPATION

<<Patient Demographics:Occupation>>

MEDICATIONS 

<<Clinical Details:Medication List>>

SMOKING STATUS

<<Clinical Details:Smoking>>

IMMUNISATIONS

<<Clinical Details:Immunisation List>>

ALLERGIES & WARNINGS

<<Clinical Details:Warnings>>

EXAMINATION
<<Summary:Progress Note (Current)>>

Patient’s Name: <<Patient Demographics:Full Name>>

GP MANAGEMENT PLAN - MBS ITEM No. 721 (DIABETES)

Patient problems / needs / relevant conditions | Goals - changes to be achieved | Required treatments and services including patient actions | Arrangements for treatments/services (when, who, contact details)
1. General | | |

Patient's understanding of diabetes

Patient to have a clear understanding of diabetes and patient's role in managing the condition

Patient education

GP / nurse
Diabetes educator

2. Lifestyle | | |

Nutrition

Maintain healthy diet

Patient education

OR
As per Lifescripts action plan

GP to monitor
Dietician

Weight

Your target: BMI < __  
Ideal: 
BMI ≤ 25 kg/m^2

Monitor
Review 6 monthly

OR
As per Lifescripts action plan

Patient to monitor
GP/nurse to review

Physical activity

Your target:
  
Ideal:
Exercise at least 30 minutes     walking or equivalent 5 or more days per week

Patient exercise routine

OR
As per Lifescripts action plan

Patient to implement

Smoking

Complete cessation

Smoking cessation strategy:
Consider:
- Quit
- Medication

OR 
As per Lifescripts action plan

Patient to manage
GP to monitor

Alcohol intake

Your target:
< __ standard drinks per day
Ideal:
≤ 2 standard drinks per day (men)
≤ 1 standard drinks per day (women)

Reduce alcohol intake
Patient education

OR 
As per Lifescripts action plan

Patient to manage
GP to monitor

3. Biomedical | | |

Cholesterol/Lipids

Your targets: 
   LDL < __
   Cholesterol < __
   HDL > __
   Triglycerides < __
Ideal:
   LDL < 2.5 mmol/L
   Cholesterol < 4.0 mmols/L
   HDL > 1.0 mmol/L
   Triglycerides < 2.0 mmol/L

Annual check

GP

Blood pressure

Your target: < __
Ideal: 
< 130/80 mm Hg

Check every 6 months

GP/nurse

HbA1c

Your target: < __
Ideal: 
≤ 7%

Check every 6 months

GP/nurse

Blood glucose level

Your target: < __
Ideal: 
< 7 mmols/L (4-6 fasting)

Daily monitoring
Check every 6 months

Patient
GP/nurse

4. Medication | | |

Medication review

Correct use of medications, minimise side effects

Patient education
Review medications

GP to review and provide education

5. Complications of diabetes | | |

Eye complications

Early detection of any problems

Eye check every year
Referral by GP

GP
Eye specialist

Foot complications

Prevent foot complications

Patient education on foot care
Patient to check feet regularly
Check feet every 6 months

GP / podiatrist / nurse
Patient
GP

Kidney damage

Avoid renal complications
Your targets:
< __ µg/min timed overnight collection
< __ mg mg/L spot collection
< __ mg/mmol women
< __ mg/mmol men albumin creatinine ratio
Ideal:
< 20 µg/min timed overnight collection
< 20 mg mg/L spot collection
< 3.5 mg/mmol women
< 2.5 mg/mmol men albumin creatinine ratio

Test for microalbuminuria annually

GP

Sexual dysfunction | Maintain sexual function | To be discussed with patient where applicable | GP
6. Driving | | |

Driving Assessment

Patient to have an understanding of their obligations while driving:
- Licensing
- Hypoglycaemia (hypo)
- Check BGL prior to driving
- Hypo equipment checked and available
- Treatment of hypo while driving

Patient education
Provide patient with:
- NDSS MD template: Diabetes and Driving
- NDSS information sheet: Hypoglycaemia and diabetes
Document discussion

Nurse/CDE/GP

Copy of GP Management Plan offered to patient?  
<<Copy of GPMP offered to patient?>>

Relevant parts of the GP Management Plan supplied to other providers?  
<<Copy of GPMP supplied to other providers?>>

GP Management Plan added to the patient’s records?  
<<GPMP added to patient's records?>>

Date service was completed:  
<<Date service completed>>

Proposed Review Date:  
<<Review date (recommended 6 months)>>

I have explained the steps and costs involved, and the patient has agreed to proceed with the service. 

Patient's Signature: _____________________________________________

GP’s Signature:  ________________________________________________	
Date:___________________

This information is provided as part of the Assessment of a person with diabetes and their fitness to drive online learning module developed by the Australian Diabetes Educators Association (2014) with funding from the NDSS.

Adapted from the ACT Medicare Local – June 2014