Care Plan, 56 y o male, non smoker, drinks 3 standard drinks a day, diabetes, family history of prostate cancer, vitamin D deficirncy, include age appropriate recommendations from the Red Book, seasonal vaccination advice,
Care Plan Details
Item: GP chronic condition management plan (Medicare item 965)
Date of care plan: [Insert date]
Patient Details
Patient: [Patient name], [DOB], [Address], [Phone]
GP: [Doctor name], [Provider number], [Clinic name], [Clinic address]
Problem List
Type 2 Diabetes Mellitus
Family history of prostate cancer
Vitamin D deficiency
Alcohol intake above recommended levels
Allergies
[Insert known allergies or “No known allergies”]
Current Medications
[List current diabetes medications, supplements, and others as relevant]
Suggested Care Plan Team / Service Providers to consider
GP – ongoing coordination and monitoring
Practice Nurse – regular chronic disease follow-up
Dietitian – support for diabetes management and alcohol moderation
Exercise Physiologist – tailored exercise program
Endocrinologist – diabetes specialist input if needed
Optometrist / Ophthalmologist – annual eye check
Podiatrist – foot care and diabetes risk reduction
Pathology – HbA1c and metabolic monitoring
Pharmacist – medication review and adherence support
GP Management Plan – Problems / Goals / Treatments / Arrangements
| Patient problems / needs / relevant conditions | SMART goals – specific, measurable, achievable, relevant, time-framed | Required treatments and services including patient actions | Arrangements for treatments / services (who, when, how, contact details) |
|---|---|---|---|
| Type 2 Diabetes Mellitus | Maintain HbA1c ≤7.0% within 6 months | Diabetes education, diet modification, increased physical activity, regular blood glucose monitoring | GP review every 3 months, Dietitian for nutritional support, Exercise physiologist for program |
| Alcohol intake above national guidelines | Reduce intake to ≤2 standard drinks per day within 3 months | Education on alcohol units, patient journal to track intake, discussion of motivators | GP and Practice Nurse monitor, Health Educator/Dietitian to support reduction plan |
| Vitamin D deficiency | Achieve and maintain serum vitamin D within reference range in 6 months | Daily supplementation, safe sun exposure, balanced diet | GP pathology review every 6 months |
| Family history of prostate cancer | Maintain awareness and participate in informed shared decision-making | Provide information on PSA risks and benefits; consider PSA testing every 2 years after informed consent | GP to discuss prostate screening; follow through with ordered tests |
| Preventive health and age-related activity | Complete age-appropriate preventive checks within next 6 months | Bowel cancer screening (iFOBT), cardiovascular risk review, blood pressure and lipids check, bone health check, mental health and falls risk screening | Practice nurse to coordinate preventive schedule; GP review as due |
| Vaccination status | Maintain up-to-date vaccinations | Annual influenza vaccine, COVID-19 booster as due, pneumococcal if not already done, tetanus every 10 years | Practice nurse to review immunisation record; administer as indicated |
Review and Follow-up
Review this plan at least every 3–6 months (Medicare item 967) or sooner if the clinical condition changes.
Date service completed: [Insert date]
Proposed review date: [Insert date]
Confirmation that the patient has agreed to the plan: Yes