Author: Nagib Ahmed

<Letterhead>

GP MANAGEMENT PLAN - MBS ITEM No. 721 (ASTHMA)

Patient’s Name: 
<PtName>

Date of Birth: 
<PtDoB>

Contact Details: | Medicare or Private Health Insurance Details:

<PtAddress>

<PtMCNo>
<PtHealthIns>

Details of Doctor:
(Patients usual Doctor or another Doctor in the practice)

Details of Patient’s Carer (if applicable):

<DrName>
<DrAddress>

Date of last Care Plan/GP Management Plan:  
<Date of last Care Plan/GPMP>

Other notes or comments relevant to the patient’s management: 
PAST MEDICAL HISTORY

<PMHAll>

FAMILY HISTORY

<FamilyHx>

SOCIAL HISTORY

<SocialHx>

OCCUPATION

<PtOccupation>

MEDICATIONS 

<CurrentRx>

SMOKING STATUS

<Smoking>

IMMUNISATIONS

<Imm>

ALLERGIES & WARNINGS

<Reactions>
<Comment>   

EXAMINATION

<TodaysVisit>

Patient’s Name: <PtName>

GP MANAGEMENT PLAN - MBS ITEM No. 721 (ASTHMA)

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)
1. General | | |

Patient's understanding of asthma

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

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

GP/ Nurse
Asthma educator
Patient

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)

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
Patient

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

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:

Ideal:
At least 30 minutes walking or equivalent 5 or more days per week

Patient exercise routine

OR 
As per Lifescripts action plan

Patient to implement

Smoking

Complete cessation

Smoking cessation strategy:
Consider:
- Quit
- Medication
OR 
As per Lifescripts action plan

Patient to manage
Quit Program
Hypnotherapist
GP/nurse to monitor

3. Biomedical | | |

Achieve best lung function

Achieve best quality of life

Best lung function on spirometry

Best PEFR

GP – intensive asthma therapy until best lung function achieved

Patient to continue with intensive asthma therapy until best lung function achieved

Patient to have regular spirometry to monitor lung function

GP

Patient

GP/Nurse
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

GP/Allergist

Patient

Patient

4. Medication | | |

Optimize medication program

Minimum medication used to maintain good symptom control

No side effects or minimum side effects from medications

GP to supervise step down of medication after effective control in place for 6-12 weeks.
GP/Nurse to organize regular spirometry 
Patient agree to return for planned review even when feeling ‘well’

GP 

GP/Nurse

Patient

Copy of GP Management Plan offered to patient?  
<Copy of GPMP offered to patient?>

Relevant parts of the GPMP supplied to other providers?  
<Copy of GPMP supplied to other providers?>

GP Management Plan added to the patient’s 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.  

Patient's Signature: _____________________________________________

GP’s Signature:  ________________________________________________	

Date:___________________