<<Fill in all field pages per above prior to clicking OK>>
DIABETES:
ITEM No: <<Select Item No.>>
 MBS ITEM No’s. (721=GPMP, 723 = TCA, 732 = GPMP REVIEW, 732 = TCA REVIEW)	

Patient’s Name: 
<<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>
Medicare No: <<Patient Demographics:Medicare Number>>	General Practitioner's Details
<<Doctor:Name>> <<Doctor:Qualifications>>
<<Doctor:Address>>
Provider Number: <<Doctor:Provider Number>>
Phone:<<Doctor:Phone>> Fax: <<Doctor:Fax>>
Email: <<Doctor:E-mail>>	
Carer's Details (if appropriate.)<<Carer's details>>	Date: <<Miscellaneous:Date>>	

PAST MEDICAL HISTORY
<<Clinical Details:History List>>

CURRENT MEDICATIONS 
<<Clinical Details:Medication List>>

ALLERGIES
<<Clinical Details:Allergies>>

VACCINATIONS
<<Clinical Details:Immunisation List>>

                                                                                   												             	
DIABETES GP Management Plan /  Team Care Arrangement / Review	

Patient Needs	Health Goals 	Initial Parameters
Date:<<Miscellaneous:Date>>	Parameters at Review 
Date:	Required Treatments and Services, including Patient Actions	
1. General					
Understanding Diabetes	Patient has a clear understanding of diabetes and their role in self management	<<Patient understands condition / self management >>		Initial and ongoing education by GP / Nurse / Diabetes educator. GP to review annually.	
2. Lifestyle					
Nutrition	Diet high in fruit , vegetables, cereals and water,  and low in fats (esp saturated fats), sugar, alcohol and salt.	<<Current diet status>>		Patient and GP to consider quality of current diet and patient to make necessary adjustments. Consider dietitian. GP to review annually.	
Control Weight
 ( BMI / Waist)	Target Weight: <<Target weight>>    
         BMI < 25  (Wt/H2)
          waist < 94 male
                   < 80 females	Wt = <<Current Weight>>
Waist= <<Waist >>
BMI=  <<BMI>>	Wt =
Waist=
BMI=	Consider current level of exercise, and current dietary habits. GP to review BMI and Waist measurment 6 monthly.	
Physical activity	Exercise >30 minutes walking or equivalent 5+ days per week	<<Current level of exercise>>		Patient to consider current level of exercise and in consultation with GP make appropriate adjustments. Consider referral to strength training. GP to review annually.	
Smoking	Complete cessation	Smoking Status: <<Smoking status>>
No. of smokes per day <<Number of smokes per day>>	
No. of smokes per day	If relevent: Consider referral to Quit (QUITLINE 131848) / medication. GP to review regularly as needed (at least annually).	
Alcohol intake	≤ 2 std drinks per day (men and women)	Current Intake: <<Current alcohol intake (inc alcohol free days)>>	Current Intake:	If relevent: Patient to set daily limit goals with support from GP. GP to monitor.  If appropriate GP to consider referral and relapse preventive drug therapy	
3. Biomedical					
Lipids	Ideal: Chol < 4.0
          Trig < 1.5
          LDL < 2.5
          HDL > 1.0	Chol =  <<Chol>>
Trig =  <<Trig>>
LDL=   <<LDL>>
HDL=  <<HDL>>	Chol =
Trig =
LDL=
HDL=	Check at least annually. Review diet and ensure healthy eating goals being met as above. Consider medication.	
BP	Ideal BP < 130/80	BP=  <<BP>>	BP=	Check at least 6 Monthly along with providing lifestyle risk factor advice	
HbA1c	Ideal HbA1c <7.0%	HbA1c=  <<HbA1c>>	HbA1c=	Check 6 Monthly	
Blood Glucose	Aim for: 4-8 random; 4-6 Fasting	<<Blood Glucose>>		Monitor your BSL>once daily	
Issues regarding blood sugar control	Recognise individual factors affecting control	<<Issues regarding blood sugar control>>			
Monitor kidney function	GP to monitor and optimize	Microalbumin = <<Microalbumin>>		GP to monitor bloods and urine annually	
4. Medication					
Correct Use of Medications	Optimal medication delivery & minimal side effects	Using medication correctly: <<Patient is using medication correctly>>		GP to educate patient regarding delivery & possible side effects. GP to review medications annually.	
Vaccination	Flu / Pneumovax	Vaccinations up to date: <<Flu / Pneumovax up to date>>			
5. Complications / Other	<<COMPLICATIONS>>				
Eyes	Identify complications and minimize risk	<<Eyes>>		Ophthal/optom every 2 years	
Kidneys		<<Kidneys>>		Check urine for Microalbumin annually	
Feet		<<Feet>>		Patient to be educated in routine checking and care of feet. GP to review 6 monthly. Consider Podiatrist	
Neurol		<<Neurol>>		GP to review annually	
Cardiovasc		<<Cardiovasc>>		GP to review annually	
Erectile Dysfuntion		<<Erectile dysfunction>>			
Other		<<Other>>			

OTHER TEAM MEMBERS:<<OTHER TEAM MEMBERS>> <<(NB: For TCA and TCA review ONLY)>> (NB: For TCA and TCA review ONLY)
Provider	Address / Phone			
<<Diabetes Educators>>
<<Endocrinologists>>							
<<Opthalmologist>>
<<Podiatrists>>
<<Exercise Physiologists>>
<<Dietician>>
<<Other team member(inc contact details / specialty)>>  				
			
Comments:  <<Other Comments>>

Resources                                                   Phone	Websites / Email	
Heart Foundation Heart Line                     Ph: 1300 362787                   	www.heartfoundation.com.au	
Diabetes Australia  (Belmont)                   Ph: 5260 3768     Helpline: 1300 136 588	www.diabetes.org.au/	
Diabetes Referral Centre                            Ph: 52 267307		
Quitline                                                       Ph: 137 848             	www.quit.org.au         email: quitnow.info.au	
GPAG / C.O.G.G strength training            Ph: 52291922		
Living Longer Living Stronger (Deakin strength training) Ph:5227 2711		
Go For Your Life                                       Ph:1300 739 899	www.goforyourlife.vic.gov.au	
Better Health Self Management Course    Ph: 5260 3333		
Australian Dietary Guidelines	www.health.gov.au/pubhlth/strateg/food/recommend.htm	

 		Date: <<Miscellaneous:Date>>
		Consent:
		I agree with the goals of this care plan and I understand the recommendations and that detail of my medical 
		history may be discussed with other providers

_____________________     			             _____________________
PATIENT SIGNATURE					   DOCTOR SIGNATURE

Review Date: <<Review Date>>

Copy of GPMP/TCA given to patient: <<Copy of GPMP/TCA given to patient>>
Review of GPMP/TCA discussed with patient: <<Reviewed Plan discussed with patient-732 only>>
Copies of GPMP/TCA sent to relevant providers: <<Copies of plan sent to relevant providers>>