<<Miscellaneous:Practice Letterhead>>

GP MANAGEMENT PLAN - MBS ITEM No. 721 (DIABETES)

Patient’s Name: <<Patient Demographics:Full Name>> | Date of Birth: <<Patient Demographics:DOB>>

Contact Details: | Medicare or Private Health Insurance Details:

<<Patient Demographics:Full Address>>

<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>

Details of Patient’s Usual GP: | Details of Patient’s Carer (if applicable):

<<Doctor:Name>>
<<Doctor:Full Address>>

Date of last Care Plan/GP Management Plan (if done):  <<Date of last Care Plan/GPMP>>

Other notes or comments relevant to the patient’s management plan: 

PAST MEDICAL HISTORY

FAMILY HISTORY

<<Clinical Details:Family History>>

MEDICATIONS 

<<Clinical Details:Medication List>>

ALLERGIES

Patient’s Name: <<Patient Demographics:Full Name>>

GP MANAGEMENT PLAN - MBS ITEM No. 721 (DIABETES)

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

Patient's understanding of diabetes

Patient to have a clear understanding of diabetes and patient's role in managing the condition

Patient education

GP / nurse
Diabetes educator

2. Lifestyle | | |

Nutrition

Maintain healthy diet

Patient education

OR
As per Lifescripts action plan

GP to monitor
Dietician

Weight

Your target: BMI < __  
Ideal: 
BMI ≤ 25 kg/m^2

Monitor
Review 6 monthly

OR
As per Lifescripts action plan

Patient to monitor
GP/nurse to review

Physical activity

Your target:
  
Ideal:
Exercise at least 30 minutes     walking or equivalent 5 or more days per week

Patient exercise routine

OR
As per Lifescripts action plan

Patient to implement

Smoking

Complete cessation

Smoking cessation strategy:
Consider:
- Quit
- Medication

OR 
As per Lifescripts action plan

Patient to manage
GP to monitor

Alcohol intake

Your target:
< __ standard drinks per day
Ideal:
≤ 2 standard drinks per day (men)
≤ 1 standard drinks per day (women)

Reduce alcohol intake
Patient education

OR 
As per Lifescripts action plan

Patient to manage
GP to monitor

3. Biomedical | | |

Cholesterol/Lipids

Your targets: 
   LDL < __
   Cholesterol < __
   HDL > __
   Triglycerides < __
Ideal:
   LDL < 2.5 mmol/L
   Cholesterol < 4.0 mmols/L
   HDL > 1.0 mmol/L
   Triglycerides < 2.0 mmol/L

Annual check

GP

Blood pressure

Your target: < __
Ideal: 
< 130/80 mm Hg

Check every 6 months

GP/nurse

HbA1c

Your target: < __
Ideal: 
≤ 7%

Check every 6 months

GP/nurse

Blood glucose level

Your target: < __
Ideal: 
< 7 mmols/L (4-6 fasting)

Daily monitoring
Check every 6 months

Patient
GP/nurse

4. Medication | | |

Medication review

Correct use of medications, minimise side effects

Patient education
Review medications

GP to review and provide education

5. Complications of diabetes | | |

Eye complications

Early detection of any problems

Eye check every 2 years
Referral by GP

GP
Eye specialist

Foot complications

Prevent foot complications

Patient education on foot care
Patient to check feet regularly
Check feet every 6 months

GP / podiatrist / nurse
Patient
GP

Kidney damage

Avoid renal complications
Your targets:
< __ µg/min timed overnight collection
< __ mg mg/L spot collection
< __ mg/mmol women
< __ mg/mmol men albumin creatinine ratio
Ideal:
< 20 µg/min timed overnight collection
< 20 mg mg/L spot collection
< 3.5 mg/mmol women
< 2.5 mg/mmol men albumin creatinine ratio

Test for microalbuminuria annually

GP

Sexual dysfunction | Maintain sexual function | To be discussed with patient where applicable | GP

Copy of GP Management Plan offered to patient?  <<Copy of GPMP offered to patient?>>

Copy / relevant parts of the GP Management Plan supplied to other providers?   <<Copy of GPMP supplied to other providers?>>

GP Management Plan added to the patient’s records?  <<GPMP added to patient's records?>>

Date service was completed:  <<Date service completed>> | Proposed Review Date:  <<Review date (recommended 6 months)>>

I have explained the steps and costs involved, and the patient has agreed to proceed with the service.  <<Steps and costs explained, patient agreed>>

 GP’s Signature:  ________________________________________________	Date:___________________

Original template compiled by Monash Division of General Practice, March 2006