Download gp management plan – palliative care

GP MANAGEMENT PLAN - MBS ITEM No 721 (Palliative Care)
Patient’s Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Contact Details:
<<Patient Demographics:Full Address>>
Medicare or Private Health Insurance Details:
<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>
Details of Patient’s Usual GP:
<<Doctor:Name>>
<<Doctor:Full Address>>
Details of Patient’s Carer (if applicable):
Date of last Care Plan/GP Management Plan (if done):
Other notes or comments relevant to the patient’s management plan:
PAST MEDICAL HISTORY
<<Clinical Details:History List>>
MEDICATIONS
<<Clinical Details:Medication List>>
ALLERGIES
Original template compiled by Monash Division of General Practice, December 2006
Patient’s Name: <<Patient Demographics:Full Name>>
GP MANAGEMENT PLAN – PALLIATIVE CARE (MBS ITEM 721)
Patient problems /
needs / relevant
conditions
1. Participation of patient
in decision making
2. Pain management
3. Symptom control:
Constipation
Incontinence
Nausea
Vomiting
Dry mouth
Shortness of breath
Goals - changes to be
achieved
Required treatments
and services including
patient actions
Arrangements for
treatments/services
(when, who, and contact
details)
Open communication
Patient and/ family actively GP
between patient, family, GP participate in treatment
Patient
and health care
decisions.
Family
professionals.
Health care professionals
Advance care planning.
Solicitor
Optimal pain management. Diagnose and treat the cause GP
of the pain.
Specialist
Community Nurse
Ensure a good nights sleep. Medication management.
Patient / family
Manage symptoms.
Discuss treatment options
with patient
Keep comfortable
Manage symptoms.
Keep comfortable
Manage symptoms
Keep comfortable
Fatigue
Help with day to day care
Skin care
Prevent and/ treat pressure
sores.
Maintain comfort.
- Diet and fluids as per
patient and family wishes
- Diligent mouth care,
monitor for oral
infections/thrush. Treat as
required.
- Ice to suck.
- Medication management
- Pain management
- Oxygen therapy as
required.
- Relaxation techniques.
- Fan, open window.
- Find optimal position to
aid breathing for patient.
Care giver for day-to-day
needs.
Home help
Care of high risk patient:
- change position frequently
- keep skin clean and dry
- lotions as needed
- treat any bed sores
- exercise arms/legs as
tolerated
- Help patient and family to
manage anxiety, anger,
depression, and /frustration.
- Medication management
Access to support
4. Psychological support
Support for patient and
family
5. Religious / spiritual
support
6. Social support
Patient / family receive
support required
Organise support services to Home help
assist patient / family
Shopping
Respite
7. Medication
Management
Protocol for medication
management
GP
Patient / Family
Community Nurse
GP
Patient
Family
Community Nurse
GP
Patient
Family
Community Nurse
GP
Patient /family
Carer
GP
Patient/family
Community Nurse
GP
Counsellor
Psychologist
Religious adviser
GP
Community nurse
Local Council
Home help
Other community services
On-going medication review GP
Specialist
Community nurse
Original template compiled by Monash Division of General Practice, December 2006
Copy of GP Management Plan offered to patient? Yes/No
Copy / relevant parts of the GP Management Plan supplied to other providers? Yes/No
GP Management Plan added to the patient’s records? Yes/No
Date service was completed:
Proposed Review Date:
I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan.
GP’s Signature: ________________________________________________ Date:___________________
Original template compiled by Monash Division of General Practice, December 2006