GP Chronic Condition Management Plan, published by AEHRC CSIRO. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/aehrc/gpccmp-fhir-ig/ and changes regularly. See the Directory of published versions
Questionnaire: GP Chronic Condition Management Plan
| Official URL: http://www.health.gov.au/assessments/GPChronicConditionManagementPlan | Version: 0.1.0 | |||
| Draft as of 2026-02-13 | Computable Name: GPChronicConditionManagementPlan | |||
GP Chronic Condition Management Plan
Structure
| LinkID | Text | Cardinality | Type | Flags | Description & Constraints |
|---|---|---|---|---|---|
  GPChronicConditionManagementPlan | GP Chronic Condition Management Plan | Questionnaire | http://www.health.gov.au/assessments/GPChronicConditionManagementPlan#0.1.0 | ||
  container | null | 0..1 | group | ||
  patient | Patient details | 0..1 | group | ||
   patient-instructions | This form has been prefilled with information that was available from the patient's health record. Upon saving, the form will be stored, but additional information entered will not be used to update the patient's health record. Changes to patient demographic information should be made in the source system. | 0..1 | display | ||
| patient-consent | Consent | 0..1 | group | ||
  patient-consent-consentforplan | Consent given to proceed with plan after discussion of the purpose, benefits, process and costs | 0..1 | boolean | ||
 patient-name | Name | 0..1 | string |  | |
| patient-preferredname | Preferred name | 0..1 | string | | |
 patient-preferredpronouns | Preferred pronouns | 0..1 | choice | | Value Set: Australian Pronouns |
 patient-dob | Date of birth | 0..1 | date | | |
 patient-age | Age | 0..1 | integer | | |
| patient-sexatbirth | Sex assigned at birth | 0..1 | choice | | Value Set: Biological Sex |
| patient-genderidentity | Gender identity | 0..1 | choice | | Value Set: Gender Identity Response |
| patient-firstnationsstatus | Aboriginal and/or Torres Strait Islander status | 0..1 | choice | | Value Set: Australian Indigenous Status |
| patient-ctg | Registered for Closing the Gap PBS Co-payment Measure (CTG) | 0..1 | boolean | | |
| patient-myagedcare | My Aged Care | 0..1 | group | ||
| patient-myagedcare-registered | Registered for My Aged Care | 0..1 | choice |  | Value Set: Yes/No/Pending |
| patient-myagedcare-number | My Aged Care Number | 0..1 | string | Enable When: patient-myagedcare-registered = | |
| patient-myagedcare-comment | Comment | 0..1 | string | ||
| patient-ndis | National Disability Insurance Scheme | 0..1 | group | ||
| patient-ndis-registered | Registered for NDIS | 0..1 | choice | | Value Set: Yes/No/Pending |
| patient-ndis-number | NDIS Number | 0..1 | string | Enable When: patient-ndis-registered = | |
| patient-ndis-comment | Comment | 0..1 | string | ||
| patient-medicare | Medicare number | 0..* | group | | |
| patient-medicare-number | Number | 0..1 | string | ||
| patient-medicare-referencenumber | Reference number | 0..1 | string | ||
| patient-medicare-expiry | Expiry | 0..1 | string | ||
| patient-contact | Contact information | 0..1 | group | ||
| patient-contact-homephone | Home phone | 0..* | string | | |
| patient-contact-mobilephone | Mobile phone | 0..* | string | | |
| patient-contact-email | 0..* | string | | ||
| patient-contact-homeaddress | Home address | 0..1 | group | | |
| patient-contact-homeaddress-nofixedaddress | No fixed address | 0..1 | boolean | ||
| patient-contact-homeaddress-details | Home address | 0..* | group | Enable When: patient-contact-homeaddress-nofixedaddress != | |
| patient-contact-homeaddress-details-streetaddress | Street address | 0..1 | string | ||
| patient-contact-homeaddress-details-city | City | 0..1 | string | ||
| patient-contact-homeaddress-details-state | State | 0..1 | choice | Value Set: Australian States and Territories | |
| patient-contact-homeaddress-details-postcode | Postcode | 0..1 | string | ||
| patient-contact-postaladdress | Postal address | 0..* | group | | |
| patient-contact-postaladdress-purpose | Purpose of use | 0..1 | string | ||
| patient-contact-postaladdress-streetaddress | Street address | 0..1 | string | ||
| patient-contact-postaladdress-city | City | 0..1 | string | ||
| patient-contact-postaladdress-state | State | 0..1 | choice | Value Set: Australian States and Territories | |
| patient-contact-postaladdress-postcode | Postcode | 0..1 | string | ||
| patient-carerdetails | Carer information | 0..* | group | ||
| patient-carerinformation-hascarer | Do you have a carer? | 0..1 | choice | | Value Set: Yes/No |
| patient-carerinformation-contact | Carer contact | 0..* | group | Enable When: patient-carerinformation-hascarer = | |
| patient-carerinformation-contact-name | Name | 0..1 | string | ||
| patient-carerinformation-contact-phone | Phone | 0..* | string | ||
| patient-carerinformation-contact-email | 0..* | string | |||
| patient-carerinformation-present | Carer present at appointment | 0..1 | choice | | Enable When: patient-carerinformation-hascarer = Value Set: Yes/No |
| patient-additionalcontacts | Additional contacts | 0..* | group | ||
| patient-additionalcontacts-type | Type | 0..1 | open-choice | Options: 5 options | |
| patient-additionalcontacts-name | Name | 0..1 | string | ||
| patient-additionalcontacts-phone | Phone | 0..* | string | ||
| patient-additionalcontacts-email | 0..* | string | |||
| patient-additionalcontacts-relationship | Relationship to patient | 0..1 | string | ||
 patient-additionalinformation | Additional information | 0..1 | text | ||
| practitioner | Practitioner details | 0..1 | group | ||
| practitioner-instructions | This form has been prefilled with information that was available from the patient's health record. Upon saving, the form will be stored, but additional information entered will not be used to update the patient's health record. | 0..1 | display | ||
| practitioner-name | Name | 0..1 | string | | |
| practitioner-phone | Phone | 0..* | string | | |
| practitioner-email | 0..* | string | | ||
| practitioner-medicareprovidernumber | Medicare provider number | 0..* | string | | |
| clinicaldetails | Clinical details | 0..1 | group | ||
| clinicaldetails-instructions | This form has been prefilled with information that was available from the patient's health record. Upon saving, the form will be stored, but additional information entered will not be used to update the patient's health record. | 0..1 | display | ||
| clinicaldetails-problemsdiagnoses | Problems/Diagnoses | 0..1 | group | ||
| clinicaldetails-problemsdiagnoses-recordedproblems | Recorded problems/diagnoses | 0..* | group | ||
| clinicaldetails-problemsdiagnoses-recordedproblems-condition | Condition | 0..1 | open-choice | | Value Set: Clinical Condition |
| clinicaldetails-problemsdiagnoses-recordedproblems-clinicalstatus | Clinical status | 0..1 | choice | Value Set: Condition Clinical Status Codes | |
| clinicaldetails-problemsdiagnoses-recordedproblems-onsetdate | Onset date | 0..1 | date | | |
| clinicaldetails-problemsdiagnoses-recordedproblems-abatementdate | Abatement date | 0..1 | date | ||
| clinicaldetails-problemsdiagnoses-newproblems | New problems/diagnoses | 0..* | group | ||
| clinicaldetails-problemsdiagnoses-newproblems-condition | Condition | 0..1 | open-choice | Value Set: Clinical Condition | |
| clinicaldetails-problemsdiagnoses-newproblems-onsetdate | Onset date | 0..1 | date | ||
| clinicaldetails-problemsdiagnoses-newproblems-comment | Comment | 0..1 | string | ||
| clinicaldetails-allergies | Adverse reaction risks | 0..1 | group | ||
| clinicaldetails-allergies-recordedallergies | Recorded adverse reaction risks | 0..* | group | ||
| clinicaldetails-allergies-recordedallergies-substance | Substance | 0..1 | open-choice | | Value Set: Adverse Reaction Agent |
| clinicaldetails-allergies-recordedallergies-status | Status | 0..1 | choice | Value Set: AllergyIntolerance Clinical Status Codes | |
| clinicaldetails-allergies-recordedallergies-manifestation | Manifestation | 0..* | open-choice | | Value Set: Clinical Finding |
| clinicaldetails-allergies-recordedallergies-comment | Comment | 0..1 | text | ||
| clinicaldetails-allergies-newallergies | New adverse reaction risks | 0..* | group | ||
| clinicaldetails-allergies-newallergies-substance | Substance | 1..1 | open-choice | Value Set: Adverse Reaction Agent | |
| clinicaldetails-allergies-newallergies-manifestation | Manifestation | 0..* | open-choice | Value Set: Clinical Finding | |
| clinicaldetails-allergies-newallergies-comment | Comment | 0..1 | text | ||
| clinicaldetails-medications | Medications (current) | 0..1 | group | ||
| clinicaldetails-medications-recordedmedications | Recorded medications | 0..* | group | ||
| clinicaldetails-medications-recordedmedications-medication | Medication | 0..1 | open-choice | | Value Set: Australian Medication |
| clinicaldetails-medications-recordedmedications-status | Status | 0..1 | choice | Value Set: Medication Statement Status Limited | |
| clinicaldetails-medications-recordedmedications-dosage | Dosage | 0..1 | text | ||
| clinicaldetails-medications-recordedmedications-indication | Indication | 0..* | open-choice | | Value Set: Medication Reason Taken |
| clinicaldetails-medications-recordedmedications-comment | Comment | 0..1 | text | ||
| clinicaldetails-medications-newmedications | New medications | 0..* | group | ||
| clinicaldetails-medications-newmedications-medication | Medication | 0..1 | open-choice | Value Set: Australian Medication | |
| clinicaldetails-medications-newmedications-dosage | Dosage | 0..1 | text | ||
| clinicaldetails-medications-newmedications-indication | Indication | 0..* | open-choice | Value Set: Medication Reason Taken | |
| clinicaldetails-medications-newmedications-comment | Comment | 0..1 | text | ||
| clinicaldetails-observations | Observations | 0..1 | group | ||
| clinicaldetails-observations-instructions | The tabled observations will display the most recent results available from the patient record. New observations may be added. | 0..1 | display | ||
| clinicaldetails-observations-maingrid | Observations | 0..1 | group | ||
| clinicaldetails-observations-maingrid-height | Height | 0..1 | group | ||
| clinicaldetails-observations-maingrid-height-lastresult | Last result | 0..1 | display | ||
 clinicaldetails-observations-maingrid-height-lastresultvalue | null | 0..1 | decimal |  | |
| clinicaldetails-observations-maingrid-height-lastresultdate | null | 0..1 | date | | |
| clinicaldetails-observations-maingrid-height-newresult | New result | 0..1 | decimal | ||
| clinicaldetails-observations-maingrid-height-value-unit | cm | 0..1 | display | ||
| clinicaldetails-observations-maingrid-height-date | New result date | 0..1 | date | ||
| clinicaldetails-observations-maingrid-weight | Weight | 0..1 | group | ||
| clinicaldetails-observations-maingrid-weight-lastresult | Last result | 0..1 | display | ||
| clinicaldetails-observations-maingrid-weight-lastresultvalue | null | 0..1 | decimal | | |
| clinicaldetails-observations-maingrid-weight-lastresultdate | null | 0..1 | date | | |
| clinicaldetails-observations-maingrid-weight-newresult | New result | 0..1 | decimal | ||
| clinicaldetails-observations-maingrid-weight-value-unit | kg | 0..1 | display | ||
| clinicaldetails-observations-maingrid-weight-date | New result date | 0..1 | date | ||
| clinicaldetails-observations-maingrid-bmi | BMI (calculated) | 0..1 | group | ||
| clinicaldetails-observations-maingrid-bmi-lastresult | Last result | 0..1 | display | ||
| clinicaldetails-observations-maingrid-bmi-newresult | New result | 0..1 | decimal | | |
| clinicaldetails-observations-maingrid-bmi-newresult-unit | kg/m2 | 0..1 | display | ||
| clinicaldetails-observations-maingrid-waistcircumference | Waist circumference | 0..1 | group | ||
| clinicaldetails-observations-maingrid-waistcircumference-lastresult | Last result | 0..1 | display | ||
| clinicaldetails-observations-maingrid-waistcircumference-newresult | New result | 0..1 | decimal | ||
| clinicaldetails-observations-maingrid-waistcircumference-newresult-unit | cm | 0..1 | display | ||
| clinicaldetails-observations-maingrid-waistcircumference-newdate | New result date | 0..1 | date | ||
| clinicaldetails-observations-maingrid-pulserate | Pulse rate | 0..1 | group | ||
| clinicaldetails-observations-maingrid-pulserate-lastresult | Last result | 0..1 | display | ||
| clinicaldetails-observations-maingrid-pulserate-newresult | New result | 0..1 | integer | ||
| clinicaldetails-observations-maingrid-pulserate-newresult-unit | /min | 0..1 | display | ||
| clinicaldetails-observations-maingrid-pulserate-newdate | New result date | 0..1 | date | ||
| clinicaldetails-observations-maingrid-pulserhythm | Pulse rhythm | 0..1 | group | ||
| clinicaldetails-observations-maingrid-pulserhythm-lastresult | Last result | 0..1 | display | ||
| clinicaldetails-observations-maingrid-pulserhythm-newresult | New result | 0..1 | choice | Value Set: Pulse Rhythm | |
| clinicaldetails-observations-maingrid-pulserhythm-newdate | New result date | 0..1 | date | ||
| clinicaldetails-observations-maingrid-oxygensaturation | Oxygen saturation | 0..1 | group | ||
| clinicaldetails-observations-maingrid-oxygensaturation-lastresult | Last result | 0..1 | display | ||
| clinicaldetails-observations-maingrid-oxygensaturation-newresult | New result | 0..1 | integer | ||
| clinicaldetails-observations-maingrid-oxygensaturation-newresult-unit | % | 0..1 | display | ||
| clinicaldetails-observations-maingrid-oxygensaturation-newdate | New result date | 0..1 | date | ||
| clinicaldetails-observations-bpgrid | Blood pressure | 0..1 | group | ||
| clinicaldetails-observations-bpgrid-bp | Blood pressure | 0..1 | group | ||
| clinicaldetails-observations-bpgrid-bp-lastresult | Last result | 0..1 | display | ||
| clinicaldetails-observations-bpgrid-bp-newresultsystolic | Systolic | 0..1 | integer | ||
| clinicaldetails-observations-bpgrid-bp-newresultsystolic-unit | mm Hg | 0..1 | display | ||
| clinicaldetails-observations-bpgrid-bp-newresultdiastolic | Diastolic | 0..1 | integer | ||
| clinicaldetails-observations-bpgrid-bp-newresultdiastolic-unit | mm Hg | 0..1 | display | ||
| clinicaldetails-observations-bpgrid-bp-newresultdate | Date performed | 0..1 | date | ||
| clinicaldetails-observations-substanceusegrid | Substance use | 0..1 | group | ||
| clinicaldetails-observations-substanceusegrid-smokingstatus | Smoking status | 0..1 | group | ||
| clinicaldetails-observations-substanceusegrid-smokingstatus-laststatus | Last status | 0..1 | display | ||
| clinicaldetails-observations-substanceusegrid-smokingstatus-newstatus | New status | 0..1 | choice | Value Set: Smoking Status | |
| clinicaldetails-observations-substanceusegrid-smokingstatus-newdate | New status date | 0..1 | date | ||
| clinicaldetails-observations-smokingstatusgrid-smokingstatus-newcomment | Comment | 0..1 | string | ||
| clinicaldetails-observations-substanceusegrid-alcoholstatus | Alcohol consumption status | 0..1 | group | ||
| clinicaldetails-observations-substanceusegrid-alcoholstatus-laststatus | Last status | 0..1 | display | ||
| clinicaldetails-observations-substanceusegrid-alcoholstatus-newstatus | New status | 0..1 | choice | Value Set: Alcohol Intake Status | |
| clinicaldetails-observations-substanceusegrid-alcoholstatus-newdate | New status date | 0..1 | date | ||
| clinicaldetails-observations-substanceusegrid-alcoholstatus-newcomment | Comment | 0..1 | string | ||
| clinicaldetails-observations-additionalinformation | Additional information | 0..1 | text | ||
| plan | Plan | 0..1 | group | ||
| plandetails-commenceddate | Date this plan commenced | 0..1 | date | ||
| plandetails-inprogress | Incomplete draft plan already exists? | 0..1 | boolean | | |
 plandetails-lastcompleteddate | Date of last completed plan | 0..1 | dateTime | ||
| plan-conditions | Conditions addressed | 0..* | group | ||
| plan-conditions-condition | Condition | 0..1 | open-choice | Value Set: Clinical Condition | |
| plan-conditions-onsetdate | Onset date | 0..1 | date | ||
| plan-conditions-comments | Comments | 0..1 | text | ||
| plan-goalstasks | Goals and tasks | 0..* | group | ||
| plan-goalstasks-problemneed | Problems/Needs | 0..* | open-choice | Value Set: Clinical Condition | |
| plan-goalstasks-details-goalsetting | Goal setting | 0..* | group | ||
| plan-goalstasks-details-goalsetting-goals | Goals | 0..1 | text | ||
| plan-goalstasks-details-goalsetting-initiator | Initiator | 0..1 | string | ||
| plan-goalstasks-details-goalsetting-targetdate | Target date | 0..1 | date | ||
| plan-goalstasks-details-goalsetting-status | Status | 0..1 | choice | Value Set: Goal Status Limited | |
| plan-goalstasks-details-goalsetting-comment | Comment | 0..1 | string | ||
| plan-goalstasks-details-interventionsactions | Interventions and actions | 0..* | group | ||
| plan-goalstasks-details-interventionsactions-interventionsactions | Interventions/Actions | 0..1 | open-choice | Value Set: Procedure | |
| plan-goalstasks-details-interventionsactions-owner | Owner | 0..1 | string | ||
| plan-goalstasks-details-interventionsactions-duedate | Due date | 0..1 | date | ||
| plan-goalstasks-details-interventionsactions-comment | Comment | 0..1 | string | ||
| plan-goalstasks-details-servicestreatments | Services and treatments | 0..* | group | ||
| plan-goalstasks-details-servicestreatments-servicestreatments | Required services and treatments | 0..1 | open-choice | Value Set: Service Type | |
| plan-goalstasks-details-servicestreatments-activity | Activity | 0..1 | open-choice | Value Set: Procedure | |
| plan-goalstasks-details-servicestreatments-provider | Provider | 0..1 | string | ||
| plan-goalstasks-details-servicestreatments-comment | Comment | 0..1 | string | ||
| notes | Notes | 0..1 | group | ||
| notes-additionalcomments | Additional notes or comments | 0..* | text | ||
| completion | Completion | 0..1 | group | ||
| completion-consentforsharing | Consent given for sharing of information with relevant healthcare providers | 0..1 | boolean | ||
| completion-proposedreview | Proposed review | 0..1 | group | ||
| completion-proposedreview-date | Date | 0..1 | date | ||
| completion-proposedreview-comment | Comment | 0..1 | string | ||
| completion-bookedreview | Booked review | 0..1 | group | ||
| completion-bookedreview-date | Date | 0..1 | date | ||
| completion-bookedreview-comment | Comment | 0..1 | string | ||
| completion-copyoffered | Patient has been offered a copy of this plan | 0..1 | choice | Options: 3 options | |
| completion-comment | Comment | 0..1 | string | ||
| Documentation for this format | |||||
Options Sets
Answer options for patient-additionalcontacts-type
- http://snomed.info/sct#394619001
- http://snomed.info/sct#1620171000168100
- http://terminology.hl7.org/CodeSystem/v2-0131#C
- http://terminology.hl7.org/CodeSystem/v2-0131#CP
- http://terminology.hl7.org/CodeSystem/v2-0131#N
Answer options for completion-copyoffered
- Yes, copy provided
- Yes, copy to be provided at a later date
- Yes, but declined
Contained Resources
This ValueSet requires the Code system Supplement GP CCMP Expanded Yes No Indicator Supplement.
Expansion based on:
This value set contains 3 concepts
Expansion based on codesystem expandedYes-NoIndicator v3.0.0 (CodeSystem)
This value set contains 2 concepts
| System | Code | Display (en) | Definition | JSON | XML |
http://terminology.hl7.org/CodeSystem/v2-0532 | Y | Yes | Yes | ||
http://terminology.hl7.org/CodeSystem/v2-0532 | N | No | No |
Expansion based on SNOMED CT Australian Edition edition 31-Jan 2026
This value set contains 4 concepts
| System | Code | Display (en) | JSON | XML |
http://snomed.info/sct | 271636001 | Pulse regular | ||
http://snomed.info/sct | 61086009 | Pulse irregular | ||
http://snomed.info/sct | 271637005 | Pulse irregularly irregular | ||
http://snomed.info/sct | 271638000 | Pulse regularly irregular |
Expansion based on codesystem Medication status codes v4.0.1 (CodeSystem)
This value set contains 4 concepts
| System | Code | Display | Definition | JSON | XML |
http://hl7.org/fhir/CodeSystem/medication-statement-status | active | Active | The medication is still being taken. | ||
http://hl7.org/fhir/CodeSystem/medication-statement-status | completed | Completed | The medication is no longer being taken. | ||
http://hl7.org/fhir/CodeSystem/medication-statement-status | stopped | Stopped | Actions implied by the statement have been permanently halted, before all of them occurred. This should not be used if the statement was entered in error. | ||
http://hl7.org/fhir/CodeSystem/medication-statement-status | on-hold | On Hold | Actions implied by the statement have been temporarily halted, but are expected to continue later. May also be called 'suspended'. |
Expansion based on:
This value set contains 3 concepts