2009 09 16GPLWB GPMP Item 721 Chronic Renal Failure

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2009 09 16GPLWB GPMP Item 721 Chronic Renal Failure Powered By Docstoc
					       GP MANAGEMENT PLAN – MBS ITEM No. 721                                                                              CHRONIC KIDNEY DISEASE (CKD)
                                         Prevent the progression of chronic kidney Failure

Patient’s Name: ………………………………………………………………………………………………………………………….



   Patient problems / needs /              Goals – changes to be achieved             Required treatments and services                 Arrangement for treatments /
      relevant conditions                                                                 including patient actions                    services (when, who, contact
                                                                                                                                                  details)
1. General
 Patient’s understanding of            Patient to have a clear                    Patient education                                 GP / Nurse
    Chronic Renal Failure                understanding of Chronic Renal
                                         Failure and the patient’s role in self-
                                         managing the condition.

 Chest pain action plan                Develop action plan                        GP and patient agree on written action            GP
                                                                                     plan on use of anti-anginals and when             Patient
                                                                                     to ring the ambulance

2. Lifestyle
 Nutrition                             Healthy eating pattern, low fat diet       Patient Education                                 GP / Nurse to advise
                                                                                   OR                                                  Patient to implement
                                                                                    as per Lifescripts action plan                    Dietitian

 Weight                                Your target:                                Monitor                                           Patient to monitor
                                        BMI ≤                                       Review 6-monthly                                  GP/ Nurse to review
                                        Waist ≤ cm                                 OR
                                        Ideal:                                      as per Lifescripts action plan
                                        BMI ≤ 25 kg/m²
                                        Men waist ≤ 94cm
                                        Women waist ≤ 80cm

 Physical Activity                     Your target:                                Patient exercise routine                          Patient to implement
                                                                                   OR                                                  GP / Nurse to review
                                        Ideal: Exercise at least 30 minutes         as per Lifescripts action plan
                                        walking or equivalent 5 or more days
                                        per week




 Smoking                              Complete cessation                          Smoking cessation strategy:                       Patient to manage
   Template compiled by Wide Bay Division General Practice, August 2006               Template available for downloading from GP Links website www.gplinks.org.au
   Adapted from Monash Division of General Practice
                                                                             Consider:                                            GP / Nurse to monitor
                                                                              QUIT
                                                                              Medication
                                                                             OR
                                                                              as per Lifescripts action plan



 Alcohol intake                        Your target:                          Reduce alcohol intake                              Patient to manage
                                        ≤      standard drinks per day        Patient education                                  GP to monitor
                                        Ideal:                               OR
                                        ≤ 2 standard drinks per day (men)     as per Lifescripts action plan
                                        ≤ 1 standard drink per day (women)

3. Biomedical
 Cholesterol / Lipids                  Your targets:                         Annual Check                                       GP
                                        Cholesterol ≤         mmols/L
                                        Triglycerides ≤       mmol/L
                                        LDL-C ≤              mmol/L
                                        HDL-C≤               mmol/L

                                        Ideal:
                                        Cholesterol < 4.0 mmols/L
                                        Triglycerides < 2.0 mmol/L
                                        LDL ≤ 2.5mmol/L
                                        HDL ≥ 1.0 mmol/L

 Blood Pressure                        Your target: <                        Check at every visit                               GP / Nurse
                                        Ideal:
                                        <130/80
 HbA1c                                 Your target: <                        Check every 3-months                               GP / Nurse
                                        Ideal: ≤ 7%

 Diabetes                              Your target:                          Patient Education                                  Diabetes Educator
                                        HbA1C ≤ ____%                         Review every 6-months                              GP / Nurse
                                        Fasting glucose ≤ _____
                                        2hr post prandial glucose ≤ ______
                                        Ideal:
                                        HbA1C ≤ 7%
                                        Fasting glucose ≤ 6
                                        2hr post prandial glucose ≤ 8



     Template compiled by Wide Bay Division General Practice, August 2006         Template available for downloading from GP Links website www.gplinks.org.au
     Adapted from Monash Division of General Practice
4. Medication

 Medication review                       Correct use of medications,        Patient education                                  GP to review and provide
                                          Minimise side effects              Review medication                                   education

 Medication Management                   Use of antiplatelet agents         Aspirin (unless contraindicated)                   GP to monitor
                                          Use of ACE inhibitors              Consider in all patients (angiotension II          GP to monitor
                                                                               receptor antagonists if develop side
                                                                               effects)
                                          Use of Beta-blockers               Consider in all post-acute coronary                GP to monitor
                                                                               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
5. Psychosocial

                                          Manage depression                  Assessment.                                        GP to assess and initiate
 Depression                                                                  Medication or cognitive behaviour                   management
                                                                               therapy

 Social isolation                        Reduce social isolation            Improve social support eg. Referral to             GP to advise and monitor
                                                                               support group



      Copy of GPMP offered to patient?  Yes                          No

      Copy / relevant parts of the GPMP supplied to other providers?  Yes          No

      GPMP added to the patient’s records?  Yes                   No

      Date service was completed: ______ / ______ / ______                                    Review Date: ______ / ______ / ______

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

      GPs Signature ___________________________________________________________               Date: ______ / ______ / ______




      Template compiled by Wide Bay Division General Practice, August 2006        Template available for downloading from GP Links website www.gplinks.org.au
      Adapted from Monash Division of General Practice
                                     CORONARY HEART DISEASE GP MANAGEMENT PLAN – MBS ITEM No. 721

Patient’s Name: ………………………………………………………….....                                        Date of Birth: …………………………………………………………...

Contact Details:……………………………………………………………..                                          Medicare or Private Health Insurance Details: …………….......

………………………………………………………………………………….                                                    ………………………………………………………………………….….

...……………………………………………………………………………….                                                 ..……………………………………………………………………………

Details of Patient’s Usual GP:                                                     Details of Patient’s Carer (if applicable):
…………………………………………………………………………………                                                    ……………………………………………………………………………..

…………………………………………………………………………………                                                    ……………………………………………………………………………..

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

If the patient has a previous or existing care plan, when was it prepared and what were the outcomes?....................................................

……………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………..

Other notes or comments relevant to the patients’ management plan:…………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………..

MEDICATIONS
……………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………..

ALLERGIES
……………………………………………………………………………………………………………………………………………………………………………..

Template compiled by Wide Bay Division General Practice, August 2006             Template available for downloading from GP Links website www.gplinks.org.au
Adapted from Monash Division of General Practice
……………………………………………………………………………………………………………………………………………………………………………..

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Template compiled by Wide Bay Division General Practice, August 2006   Template available for downloading from GP Links website www.gplinks.org.au
Adapted from Monash Division of General Practice

				
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