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Diabetes Self Management Plan _item 721_

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					                            DIABETES SELF-MANAGEMENT PLAN – 721                                                                      REVIEW – 725

                                            «practicename» Phone: «practicephone» fax: «practicefax»
Patient Details                        GP Details:                 Patient agreement for the GP Management Plan proceed
[PAT_FIRSTNAME] [PAT_SURNAME]          [GP_GIVENNAME]              My GP has explained the steps & costs of the GP Management Plan & I agree to proceed.                                Yes
[PAT_HOME_STREET],                     [GP_SURNAME]
[PAT_HOME_SUBURB],
[PAT_HOME_POSTCODE],                   [GP_REG_NO]                 Where I am referred to other service providers as listed on this GP Management Plan, I consent to my GP sharing      Yes
[PAT_HOME_STATE]                                                   relevant information about myself to that provider. I have advised my GP of any information I wish to be withheld.
HOME Ph: [PAT_HOME_PHONE]
DOB: [PAT_DOB]                                                     I understand that [LOC_NAME]        has one health record for patients and that this record is shared by       Yes
AGE: [PAT_AGE]
                                                                   all [LOC_NAME]       health team providers




                            GOALS FOR MANAGEMENT                                                                           What is my role?                                   Who will do this?

BGL:                            4 – 6 mmol/L (Fasting)
Hba1c:                          ≤ 7%
LDL Cholesterol:                < 2.5 mmol/L
Cholesterol:                    < 4.0 mmol/L
HDL Cholesterol:                > 1.0 mmol/L
Triglycerides:                  < 1.5 mmol/L
Blood Pressure:                 < 130/80 mm Hg

BMI:                            < 25 Kg/m2 - where applicable

Urinary albumin excretion: < 20 g/min
                           < 20 mg/ spot collection
                           < 3.5 mg/mmol women
                           < 2.5 mg/mmol men albumin creatine ration

Cigarette consumption:          Zero

Alcohol intake:                 ≤ 4 standard drinks (40g)/day (men)
                                ≤ 2 standard drinks (20g)/day (women)

Physical activity               at least 30 minutes walking (or equivalent)
                                  5 or more days/week (total ≥ minutes/week)

Eye checks:                       Every two years minimum

Foot checks:                      Every six months
Other recommendations:

Capacity to self manage
    I have explored readiness for change and barriers for self management
    I have checked that the patient has enough knowledge, confidence and family support to manage the condition

Contacts and further Information
In case of Emergency:          (i.e. Nurse on Call, GP, Nurse, etc)
Dietician:
Podiatrist:
Eye specialist:
Diabetes educator:
Quitline Tel. 131 848
Diabetes Australia – Vic Tel. 1300 136 588
Baker IDI Heart and Diabetes Institute Tel. (03) 9258 5000
Life! Taking Action on Diabetes Tel. 13 RISK (13 7475) – for information about preventing your risk of type 2 diabetes or to take a risk test online


 A copy of this plan has been given to the patient.   Yes                                   This section is only to be completed at Review appointment
 Charge item 721                                                                            Review Date
 Enter recall for review 6 months
 Enter recall for new plan 2 years                                                          Enter recall for review 6 months

 DATE COMPLETED: [MIS_TODAYL]                                                               Claim item 725

				
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