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
Asthma
Elevated blood pressure
Overweight/Obesity (BMI 31)
Allergies
[Insert known allergies or “No known allergies”]
Current Medications
[List current asthma relievers / preventers or antihypertensives if prescribed]
Suggested Care Plan Team / Service Providers to consider
GP – monitoring and coordination
Practice Nurse – ongoing education and monitoring
Paediatrician – review asthma and BP management
Dietitian – support for healthy eating and weight control
Exercise Physiologist / Physiotherapist – structured child-appropriate physical activity
Asthma Educator – inhaler and trigger management support
Pharmacist – medication technique 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) |
|---|---|---|---|
| Asthma | Maintain good control with <2 reliever uses per week within 3 months | Regular preventer use as prescribed, trigger avoidance education, asthma action plan | GP review every 3 months, Practice Nurse asthma review, Paediatrician if inadequate control |
| High blood pressure | Achieve normal BP for age range within 6 months | Monitor BP regularly, review contributing factors (salt intake, screen time, activity) | GP and Practice Nurse to monitor, Paediatrician review as indicated |
| Overweight / BMI 31 | Reduce BMI by 5–10% over 6–12 months | Balanced diet following Australian Guide to Healthy Eating, increased daily physical activity (≥60 min/day), reduced sugary drinks and screen time | Dietitian and Exercise Physiologist input, home/family lifestyle plan |
| Preventive health – age appropriate | Maintain routine health monitoring and vaccinations | Growth and development checks, oral health review, ensure complete immunisation per Australian Immunisation Schedule, annual influenza vaccine | GP/Practice Nurse to coordinate; Dentist for 6–12 month review |
| Lifestyle modifications | Increase family-based physical activity and reduce sedentary habits | Family walking, sports participation, screen-free evenings | Family and Practice Nurse follow-up; review adherence at GP appointments |
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 (parent/guardian consent): Yes