<<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 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

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 (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/m2	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?>>

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. 

Patient's Signature: _____________________________________________

GP’s Signature:  ________________________________________________	
Date:___________________