CARE PLAN

ITEM: 	GP Management Plan  ____ 721	
	TCA    ____ 723                                                     

PATIENT DETAILS: | GP DETAILS:
[Patient Demographics:Full Details] | [Doctor:Full Details]
DATE CARE PLAN PREPARED: [Miscellaneous:Date]
PROBLEM LIST:
[Clinical Details:History List]

ALLERGIES:
[Clinical Details:Allergies]

CURRENT MEDICATIONS:
[Clinical Details:Medication List]

[Clinical Details:Measurement BP]

[Clinical Details:Measurements]

CARE PLAN TEAM MEMBERS or if GPMP - SERVICE PROVIDERS:
NAME | TYPE OF CARE | if developing a TCA CONTACTED/ COPY SENT | if developing TCA AGREED?
[Doctor:Name] | GP (details above) | yes | yes
[Addressee:Full Details] | [Addressee:Specialty] | yes | yes
[Addressee:CC Full Detail (Selected)] | | |

GP MANAGEMENT PLAN – PALLIATIVE CARE (MBS ITEM 721)

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

1. Participation of patient in decision making

Open communication between patient, family, GP and health care professionals.

Patient and/ family actively participate in treatment decisions.

Advance care planning.

GP
Patient 
Family
Health care professionals
Solicitor

2. Pain management

Optimal pain management.

Ensure a good nights sleep.

Diagnose and treat the cause of the pain. 

Medication management.

GP
Specialist
Community Nurse
Patient / family

3. Symptom control: | | |

Constipation 
Incontinence

Manage symptoms.

Keep comfortable

Discuss treatment options with patient

GP
Patient / Family
Community Nurse

Nausea
Vomiting
Dry mouth

Manage symptoms.

Keep comfortable

- Diet and fluids as per patient and family wishes
- Diligent mouth care, monitor for oral infections/thrush. Treat as required.
- Ice to suck.
- Medication management

GP
Patient
Family
Community Nurse

Shortness of breath

Manage symptoms

Keep comfortable

- Pain management
- Oxygen therapy as required.
- Relaxation techniques.
- Fan, open window.
- Find optimal position to aid breathing for patient.

GP
Patient
Family
Community Nurse

Fatigue

Help with day to day care

Care giver for day-to-day needs.
Home help

GP
Patient /family
Carer

Skin care

Prevent and/ treat pressure sores.

Maintain comfort.

Care of high risk patient:
- change position frequently
- keep skin clean and dry
- lotions as needed
- treat any bed sores
- exercise arms/legs as tolerated

GP
Patient/family
Community Nurse

4. Psychological support

Support for patient and family

- Help patient and family to manage anxiety, anger, depression, and /frustration. 
- Medication management

GP 
Counsellor
Psychologist

5. Religious / spiritual support | Patient / family receive support required | Access to support | Religious adviser

6. Social support

Organise support services to assist patient / family

Home help
Shopping
Respite

GP
Community nurse
Local Council
Home help
Other community services

7. Medication Management

Protocol for medication management

On-going medication review

GP
Specialist
Community nurse

Copy of GP Management Plan offered to patient?  y

Copy / relevant parts of the GP Management Plan supplied to other providers?  y

GP Management Plan added to the patient’s records?  y

Date service was completed: | Proposed Review Date:

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