You are on page 1of 3

<<Miscellaneous:Practice Letterhead>> GP MANAGEMENT PLAN - MBS ITEM No.

721 (ASTHMA)
Patients Name: <<Patient Demographics:Full Name>> Contact Details: <<Patient Demographics:Full Address>> Details of Patients Usual GP: <<Doctor:Name>> <<Doctor:Full Address>> Date of Birth: <<Patient Demographics:DOB>> Medicare or Private Health Insurance Details: <<Patient Demographics:Medicare Number>> <<Patient Demographics:Health Insurance>> Details of Patients Carer (if applicable):

Date of last Care Plan/GP Management Plan (if done): <<Date of last Care Plan/GPMP>> Other notes or comments relevant to the patients care planning:

PAST MEDICAL HISTORY <<Clinical Details:History List>> FAMILY HISTORY <<Clinical Details:Family History>> MEDICATIONS <<Clinical Details:Medication List>> ALLERGIES - Patient to have continuing responsibility for their asthma and attend for regular review.

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

Patients Name: <<Patient Demographics:Full Name>>


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) GP/ Nurse Asthma educator Patient GP Patient

1. General Patient's understanding Patient to have a clear of asthma understanding of asthma and the patient's role in self management.. 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).

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

Patient education (using patient education checklist). Ongoing asthma education by GP/Nurse during regular reviews. 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 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:

Patient exercise routine

Patient to implement


Ideal: OR At least 30 minutes walking As per Lifescripts action plan or equivalent 5 or more days per week Complete cessation Smoking cessation strategy: Consider: - Quit - Medication OR As per Lifescripts action plan Achieve best quality of life Best lung function on spirometry Best PEFR GP intensive asthma therapy until best lung function achieved

Patient to manage Quit Program Hypnotherapist GP/nurse to monitor

3. Biomedical Achieve best lung function


Patient to continue with intensive asthma therapy until best lung function Patient achieved Patient to have regular spirometry to monitor lung function GP/Nurse Patient GP/Allergist Patient 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

4. Medication Optimize medication

Minimum medication used to GP to supervise step down of


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


maintain good symptom control

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

GP/Nurse Patient

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 patients 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>> GPs Signature: ________________________________________________ Date:___________________

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