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<<Miscellaneous:Practice Letterhead>>


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>>
Provider Number: <<Doctor:Provider Number>>

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

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


<<Clinical Details:History List>>

<<Clinical Details:Family History>>

<<Clinical Details:Social History>>

<<Clinical Details:Medication List>>

<<Clinical Details:Allergies>>

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

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

GP MANAGEMENT PLAN - MBS ITEM No. 721 (Coronary Heart Disease CHD)
Applies to acute coronary syndromes, myocardial infarction, coronary angioplasty with/without stenting, and
bypass surgery. Similar guideline for other vascular disease (peripheral and cerebrovascular)
Patient problems / Goals - changes to be Required treatments and Arrangements for
needs / relevant achieved (if possible) services including patient treatments/services
conditions actions (when, who, and
contact details)
1. General
Patient's understanding Patient to have a clear Patient education GP/nurse
of coronary heart understanding of coronary heart
disease disease and the patient's role in
managing the condition
Chest pain action Develop action plan GP and patient agree on GP
plan written action plan on use of Patient
anti-anginals and when to
ring the ambulance
2. Lifestyle
Nutrition Healthy eating pattern, low fat diet Patient education GP/nurse to advise
Patient to implement
OR Dietitian
As per Lifescripts action plan
Weight Your target: Monitor Patient to monitor
BMI ≤ Review 6 monthly GP/nurse to review
Waist ≤ cm
Ideal: OR
BMI ≤ 25 As per Lifescripts action plan
Men waist ≤ 94 cm
Women waist ≤ 80 cm
Physical Activity Your target: Patient exercise routine Patient to implement
GP/nurse to review
Ideal: OR
At least 30 minutes walking or As per Lifescripts action plan
equivalent 5 or more days per
Smoking Complete cessation Smoking cessation strategy: Patient to manage
Consider: GP/nurse to monitor
- Quit
- Medication

As per Lifescripts action plan
Alcohol Your target: Reduce alcohol intake Patient to manage
≤ standard drinks per day Patient education GP to monitor
≤ 2 standard drinks per day OR
(men) As per Lifescripts action plan
≤ 1 standard drinks per day
2. Biomedical
Cholesterol / Lipids Your target: Annual check GP
Cholesterol ≤ mmols/L
Triglycerides ≤ mmol/L
LDL-C ≤ mmol/L
HDL-C ≥ mmol/L
Cholesterol ≤ 4.0 mmols/L
Triglycerides ≤ 2.0 mmol/L
LDL-C ≤ 2.5 mmol/L
HDL-C ≥ 1.0 mmol/L
Blood pressure Your target: < Check every 6 months GP / nurse
< 140/90

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

Diabetes Your target: Patient education GP / nurse
HbA1C ≤ __% Review every 6 months Diabetes educator
Fasting glucose ≤ __
2hr post prandial glucose ≤ __
HbA1C ≤ 7%
Fasting glucose ≤ 6
2hr post prandial glucose ≤ 8
3. Medication
Medication review Correct use of medications, Patient education GP to review and provide
minimise side effects Review medications education
Medication Use of antiplatelet agents Aspirin (unless contraindicated) GP to monitor
Use of ACE inhibitors Consider in all patients GP to monitor
(angiotension II receptor
antagonists if develop side
Use of Beta-blockers Consider in all post-acute GP to monitor
coronary syndromes
Use of Statins In all unless contraindicated GP to monitor
Use of Anticoagulants Warfarin if high risk of GP to monitor
thromboembolism post-
myocardial infarction
4. Psychosocial
Depression Manage depression Assessment. GP to assess and initiate
Medication or cognitive management
behaviour therapy
Social isolation Reduce social isolation Improve social support GP to advise and monitor
eg referral to support group

Copy of GP Management Plan offered to patient?

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

GP Management Plan added to the patient’s records?

Date service was completed: Proposed Review Date:

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

GP’s Signature: ________________________________________________ Date:___________________

GP Name: <<Doctor:Name>>

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