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GP Management Plan / Team Care Arrangement – ARTHRITIS
Patients Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Does patient identify as Aboriginal or Torres Strait Islander: <<Does patient identify as ATSI?>>
Medicare No: <<Patient Demographics:Medicare Number>>
Pension No: <<Patient Demographics:Pension Number>>
Date of GPMP/TCA: <<Miscellaneous:Date>>
Details of Patient's Usual GP: <<Doctor:Name>>
Assessment of patient
Date diagnosis of Arthritis: <<Date diagnosis of Arthritis>>
Type of Arthritis: <<Type of Arthritis>>
Previous Care Plan (date, objectives): <<Previous Care Plan (date, objectives)?>>
Medical / Surgical History:
<<Clinical Details:History List>>
Medications:
<<Clinical Details:Medication List>>
Allergies:
<<Clinical Details:Allergies>>
Social History:
<<Clinical Details:Social History>>
Patient identified problems / health care needs:
<<Patient identified problems / health care needs?>>
I have explained the steps and costs involved, and the patient has agreed to proceed with the
service and gives their consent _______________________________________(GP Sign & Date)
Copy of GPMP given to patient: <<Copy of GPMP given to patient?>>
Relevant copies of GPMP/TCA given to other providers: <<Relevant copies of TCA given to other
providers?>>
Patient Consent & Date: ________________________________________________
Planned Review Date: <<Planned Review Date?>>
Problem/condition Current Required Actions by Arrangements for
Measurements & the patient/GP / other Providers and
Goals practice nurse Services (complete for
Problem/condition (complete for a Team Care
a GP Management Arrangement)
Plan)
1. General
Patient Patient will have a Review annually or as GP/Practice
understanding of clear understanding condition changes nurse/Arthritis
arthritis of arthritis and their SA/Rheumatologist/
role in managing the Orthopaedic Surgeon
condition
2. Arthritis Management
Pain management Optimal pain Pain management GP/Patient
management appropriate to patient
needs
Southern Division of General Practice October 2007
Optimising Optimal function and Home aids/modification. GP/Podiatrist/OT
function/mobility mobility Review of footwear
Medication Ensure appropriate Review regularly GP/practice
use of medications nurse/Home
and minimise Medications
side-effects review/other specialist
Complementary Identify and review Review regularly GP
therapy use of
complementary
medication
Specific joint Minimise specific Joint specific therapy GP/Rheumatologist/
problems joint problems Orthopaedic surgeon
Surgical Improve mobility and Assess suitability for GP/Rheumatologist/
intervention reduce pain surgical intervention Orthopaedic Surgeon
including joint
replacement therapy
MAPT Score:
Physical activity Your target: Patient education GP/practice nurse to
Ideal: Exercise regime monitor
Moderate physical Chronic Disease Self
activity for 30 mins Management
per day most days of Programs/Physio
the week Activity program/
Exercise group
3. Lifestyle
Weight & waist Your BMI: Check every 6 months GP/Practice nurse
circumference Your waist
circumference:
Last BMI: Ideal:
BMI between 20-25
Last weight: Waist
circumference:
<90cm (men)
<84cm (women)
Nutrition Maintain healthy diet Diet advice/patient GP/practice nurse to
education monitor
Dietitian,
Smoking Current Smoking Support for quitting: Patient managed
status: Quitline GP/practice nurse to
Nicotine Replacement monitor
Medication
Ideal : Quit smoking
Alcohol Intake Current alcohol Promote reduction of GP to monitor
intake: alcohol and
…..standard drinks regular alcohol free days
per day
Ideal:
Men: </= 2 standard
drinks per day
Women: </= 1
standard drink per
day
Immunisation Your current Influenza vaccine every GP/Practice nurse
status vaccination status: year
Southern Division of General Practice October 2007
Influenza – Pneumococcal vaccine –
Pneumococcal- initial
Tetanus vaccine then booster
after 5 years
Tetanus vaccine –
booster aged 50 years (if
none in previous 5 years)
Psychosocial/ment Prevention and early Consider screening GP/Practice nurse
al health issues detection of using assessment tool if
psychosocial appropriate (DASS, K10)
problems
Southern Division of General Practice October 2007
