Chronic Condition Self Management
Care Plan for CVCP Participants

SURNAME: <<Patient Demographics:Surname>>
GIVEN NAME: <<Patient Demographics:First Name>>
DOB: <<Patient Demographics:DOB>>	SEX: <<Patient Demographics:Sex>>
ADDRESS: <<Patient Demographics:Address>>

Care Plan Compiled by

Name | Position | Contact Number | Received copy of Care Plan YES/NO

Services Already Involved:

Provider | Contact Details | Comments
General Practitioner (GP) | |
Practice Nurse | |
Community Nursing Service | |
Home and Community Care (HACC) | |
Departments of Veteran Affairs | |
Rural Primary Health Program | |
Allied Health | |

Diagnosis / Co Morbidities

1. | 6.
2. | 7.
3. | 8.
4. | 9.
5. | 10.

SURNAME: <<Patient Demographics:Surname>>
GIVEN NAME: <<Patient Demographics:First Name>>
DOB: <<Patient Demographics:DOB>>	SEX: <<Patient Demographics:Sex>>
ADDRESS: <<Patient Demographics:Address>>

____________________________________________________________________________________________________________

Client's overall goal/s:

Issues Identified | Goals | Interventions

Review Ratings

4 = Achieved	3 = Good Progress	2 = Some Progress	1 = No Progress

Person Responsible | Date Initiated | Date of Review with Review Rating | Date of Review with Review Rating | Date of Review with Review Rating | Progress

Sign Off - Client

I ______________________________ (Patient's name) agree that the information contained within this care plan is true and correct and currently reflects my needs for the forthcoming year. Additionally, I consent to this information relevant to my care being released to other health providers.

Signature: ___________________________ 		Date:  . . . . / . . . . / . . . .

Sign Off - Health Professional

I ______________________________ (Health Professional's name) agree that the services prescribed within this care plan is true and correct at the time of development but are subject to review based on the client's needs and / or my professional opinion as the responsible Health Care Professional.

Signature: ___________________________ 		Position: ____________________________

Date:  . . . . / . . . . / . . . .

Sign Off - Health Professional (e.g. GP, Specialist)

I ______________________________ (Health Professional's name) agree that the services prescribed within this care plan is true and correct at the time of development but are subject to review based on the client's needs and / or my professional opinion as the responsible Health Care Professional.

Signature: ___________________________ 		Position: ____________________________

Date:  . . . . / . . . . / . . . .				Provider Number: _____________________

CARE PLAN CHECKLIST

•   Re-evaluate client goals
•   Disease specific education
•   Physical exercise/activity
•   Seasonal weather changes
•   Nutritional advice
•   General Practitioner/Specialist Review
•   Medication reviews
•   Smoking Cessation
•   Ed presentation or hospital admissions
•   Lifestyle changes (energy conservation)
•   Psychological needs
•   Carer/social/ financial issues
•   Transport issues
•   Environment issues (housing issues, house assessment)