| GP MANAGEMENT PLAN |
| Patient problems / needs / relevant conditions | Goals – changes to be achieved (if possible) | Required treatments and services including patient actions | Arrangements for treatments/services (when, who, and contact details) |
| 1. General | |||
| Diabetes. | Increase patient’s understanding of Diabetes. | Patient education – lifestyle. | GP |
| Blood sugar level control | BSL in normal range < 6 fasting; <11 random. (at list aim to) | assess patient’s way of self-monitoring: support, educate. Monitor | GP |
| Blood pressure control. | Aim for blood pressure 130/75. | Monitor, review medications, patient education. | GP |
| Lipids | LDL-C <2.5 mmol/LTC < 3.5 mmol/LHDL-C > 1.1 mmol/LTryglyceride < 2.0 mmol/L | Monitor, review medications, patient education. | GP |
| Future complications. | To prevent/minimise the long-term effects of Diabetes on body. To manage medication. | Annual complication assessment & review. Adjustment of medication. | Consultant physician |
| 2. Lifestyle | |||
| Nutrition | Healthy eating pattern, low fat diet | Patient education OR As per Lifescripts action plan | GPPatient to implementDietitian |
| Weight | Your target:BMI ≤ 25Men waist ≤ 94 cmWomen waist ≤ 80 cm | MonitorReview 6 monthly | Patient to monitorGP |
| Physical Activity | Your target:At least 30 minutes walking or equivalent 5 or more days per week | Patient exercise routine | Patient to implementGP |
| Smoking | Complete cessation | Smoking cessation strategy:Consider:- Quit- Medication | Patient to manageGP |
| Alcohol | Your target:≤ standard drinks per dayIdeal:≤ 2 standard drinks per day (men)≤ 1 standard drinks per day (women) | Reduce alcohol intakePatient education | Patient to manageGP to monitor |
| 2. Biomedical | |||
| Cholesterol / Lipids | Your target:Cholesterol ≤ 4.0 mmols/LTriglycerides ≤ 2.0 mmol/LLDL-C ≤ 2.5 mmol/LHDL-C ≥ 1.0 mmol/L | Annual check | GP |
| Blood pressure | Your target:< 140/90 | Check every 6 months | GP |
| 3. Medication | |||
| Medication review | Correct use of medications, minimise side effects | Patient educationReview medications | GP to review and provide education |
| 4. Psychosocial | |||
| Risk of Depression | Manage depression | Assessment.Medication or cognitive behaviour therapy | GP to assess and initiate management |