<<Miscellaneous:Practice Letterhead>>

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

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 Doctor:
(Patients usual Doctor or another Doctor in the practice)	Details of Patient’s Carer (if applicable):	
<<Doctor:Name>>
<<Doctor:Full Address>>	

Date of last Care Plan/GP Management Plan:  
<<Date of last Care Plan/GPMP>>

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

	
PAST MEDICAL HISTORY

<<Clinical Details:History List>>

FAMILY HISTORY

<<Clinical Details:Family History>>

SOCIAL HISTORY

<<Clinical Details:Social History>>

OCCUPATION

<<Patient Demographics:Occupation>>

MEDICATIONS 

<<Clinical Details:Medication List>>

SMOKING STATUS

<<Clinical Details:Smoking>>

IMMUNISATIONS

<<Clinical Details:Immunisation List>>

ALLERGIES & WARNINGS

<<Clinical Details:Warnings>>   

EXAMINATION

<<Summary:Progress Note (Current)>>

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

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

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 asthma	Patient to have a clear understanding of asthma and the patient's role in self management	Patient education (using patient education checklist).
Ongoing asthma education by GP/Nurse during regular reviews.	GP/ Nurse
Asthma educator
Patient	
Minimise symptoms	Absent or minimal symptoms
No nocturnal or early morning symptoms.
No exertional cough or wheeze.
Absent or minimal reliever medication use (less than 3 times a week)
	GP to assess asthma severity when patient is stable (asthma history checklist may help) and individualise treatment.
Patient to keep symptom diary or PEFR diary.
Patient to adhere to preventer medication routine.
Patient to take continuing responsibility for their asthma and attend for regular review.	GP
Patient	
Asthma action plan	Patient is in control of their asthma and not vice versa

Patient is able to detect any deterioration in asthma and respond appropriately.

Patient knows when to and how to obtain prompt medical attention	GP to formulate and provide a written asthma action plan and discuss with patient.

Patient to use asthma action plan and have it reviewed regularly	GP
Patient	
2. Lifestyle				
Physical Activity

	Your target:

Ideal:
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
Quit Program
Hypnotherapist
GP/nurse to monitor	
3. Biomedical				
Achieve best lung function

	Achieve best quality of life

Best lung function on spirometry

Best PEFR	GP – intensive asthma therapy until best lung function achieved

Patient to continue with intensive asthma therapy until best lung function achieved

Patient to have regular spirometry to monitor lung function
	GP

Patient

GP/Nurse
Patient	
Maintain best lung function

	Reduce the frequency and severity of asthma attacks

Prevent the permanent development of abnormal lung function
	GP help patient identify trigger factors

Patient to avoid trigger factors if possible

Patient to use preventers regularly	GP/Allergist

Patient

Patient	
4. Medication				
Optimize medication program

	Minimum medication used to maintain good symptom control

No side effects or minimum side effects from medications	GP to supervise step down of medication after effective control in place for 6-12 weeks.
GP/Nurse to organize regular spirometry 
Patient agree to return for planned review even when feeling ‘well’	GP 

GP/Nurse

Patient	

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

Relevant parts of the GPMP 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.  

Patient's Signature: _____________________________________________

GP’s Signature:  ________________________________________________	

Date:___________________