<<Miscellaneous:Practice Letterhead>>

GP MANAGEMENT PLAN - MBS ITEM No 721 (Palliative Care) 	

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

<<Clinical Details:History List>>

FAMILY HISTORY

<<Clinical Details:Family History>>

MEDICATIONS 

<<Clinical Details:Medication List>>

ALLERGIES

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

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?  
<<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:  
<<Proposed review date (recommended 6 months)>>	

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

GP’s Signature:  ________________________________________________	

Date:___________________