<<Miscellaneous:Practice Letterhead>>
Review of GP Management Plan and/or Team Care Arrangement
(MBS item 732 in person/ 92028 telehealth via video/ 92072 telehealth via phone)
Patient’s Name: <<Patient Demographics:First Name>>	Date of Birth: <<Patient Demographics:DOB>>	

Contact Details:		Medicare or Private Health Insurance Details:	
<<Patient Demographics:Full Address>>
Tel: <<Patient Demographics:Phone (Home)>>Mob:  <<Patient Demographics:Phone (Mobile)>>	Medicare No. <<Patient Demographics:Medicare Number>>Exp: <<Patient Demographics:Medicare Expiry Date>>
Health Fund:  <<Patient Demographics:Health Insurance>>	

Details of Patient’s Usual GP:	Details of Patient’s Carer (if applicable):	
<<Doctor:Full Details>>
	Name: <<Name of patient's carer (if applicable)>>
Relationship to Patient: <<Relationship of carer to patient>>
Tel: <<Contact telephone or mobile no. of carer>>	
Medications	<<Clinical Details:Medication List>>	
Allergies	<<Clinical Details:Allergies/Adverse Reactions>>	
Past Medical History	<<Clinical Details:History List>>	
Discussion point	Rationale	Patient agreed plan/goals	
Flu vaccine 
+/- pneumonia
+/- shingles
+/- child/adolescent Imms
+/- antenatal pertussis
	High risk population
Hospital avoidance strategy
Reduce multiple excursions from home
Improve immunisation coverage rates for vaccine preventable diseases
		
Medications
How to obtain script from GP
How to organise delivery from Pharmacy
	Reduce risk of medication errors or sub-optimal treatment
Hospital avoidance strategy
Reduce unnecessary excursions from home		
Self isolation

	Vulnerable population
May not understand what this really means
Identify access and barriers to resources		
Home delivery/visiting Groceries – priority access
Pathology (if required)

	Reduce unnecessary excursions from home 
Access to essential supplies for health and hygiene
Ensure regular pathology monitoring is maintained as appropriate for patient needs		
Diet
Diabetes
High cholesterol
Obesity/Underweight
Osteoporosis
Anaemia 	Some staples in limited supply
Patients may not be familiar with available ingredients
Diet controlled chronic diseases may be affected by food availability
Available food may potentially interact with medications (e.g Warfarin)		
Discussion point	Rationale	Patient agreed plan/goals	
Skin Integrity – 
Wounds
Rashes 
Skin concerns

	Likely not attending routine skin cancer checks
May be self caring for wounds at risk of infection
Rashes could be known or unknown co-morbidities
Reactions to diet changes or using unfamiliar brands
Hands may be affected by frequent handwashing/ use of alcohol based sanitisers		
Injury Risks - 
Falls
Dizzy episodes
Recurrent Headaches
Chronic pain
	Falls risk assessment to reduce potential injuries
May be completing DIY/Home maintenance while home 
Working from home may not be ideally ergonomic
Increased screen time may strain eyes, neck 
Lack of regular movement may cause stiff joints		
Gastric changes – 
nausea/ vomiting?
change in bowel movements

	Anxiety related
Medication related 
Diet related
Prevention of compaction or new abdominal issues		
Mobility and movement	Maintaining exercise needs for chronic disease
Regular activities likely not occurring 
Promote sunshine and fresh air for good health

		
Team Care
Allied Health
Specialists
Community supports
Formal/Informal care	Usual providers may not be available
Are home visits or telehealth consults available
Access/barriers to providers
Podiatrist - how will you maintain your nails and feet
Physio/ EP - list of stretches etc to follow 

Discussion point	Rationale	Patient agreed plan/goals	
Scheduled care interventions	Prolia – MUST be given on time
Depo/ Implanon/ Mirena due dates
Iron infusions/ Venesection
BP checks/ Weight/ Waist measurements
B12 Injections
INR checks – come in or use home pathology?		
Mental health
Self care 
Staying connected to friends and family
	What? 
Who? 
How? 
Access and barriers
		
Behaviours
Alcohol intake
Smoking
Drug use
	May be increased or taken up old habits due to stress
Identify risks of potential harm		
Employment

	Psychosocial implications
Potential financial concerns
		
Housing Security	Reduce risk of homelessness
Identify possible overcrowded living conditions
Access and barriers to appropriate hygiene, cooking, heating/cooling facilities
		
Personal safety
In own home 
With the people around you	Domestic Violence/ Elder abuse related to stress, health, financial concerns, home more than usual

Agreed indications to make an appointment to see GP
via Telehealth or in person

	
Agreed indications to phone an Ambulance or go to Hospital

Previous plan consulted and reviewed
	<<Previous care plan / TCA consulted and reviewed>>	
Copy of this plan offered to patient
	<<Copy of this plan offered to patient?>>	
Patient understands and agrees to this review of their GP Management Plan and/or Team Care Arrangement
	<<Patient understands and agrees to review of plan?>>	
Date service provided	<<Date of provision of service>>	
Date this plan is to be reviewed	<<Date for next review of care plan>>	

GP Signature: ___________________________________________ Date: <<Miscellaneous:Date>>