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 2025-12-05 | 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 | ||
   instructions | This GP Chronic Condition Management Plan has been prefilled with information that was available from the patient's health record. Upon saving this form, the form will be stored but additional information entered will not be used to update the patient's health record. | 0..1 | display | ||
 patient | Patient details | 0..1 | group | ||
  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/NA |
 patient-myagedcare-number | My Aged Care Number | 0..1 | string | Enable When: patient-myagedcare-registered = | |
| patient-ndis | National Disability Insurance Scheme | 0..1 | group | ||
| patient-ndis-registered | Registered for NDIS | 0..1 | choice | | Value Set: Yes/No/NA |
| patient-ndis-number | NDIS Number | 0..1 | string | Enable When: patient-ndis-registered = | |
| 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-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-contact-homephone | Home phone | 0..* | string | | |
| patient-contact-mobilephone | Mobile phone | 0..* | string | | |
| patient-contact-emergencycontact | Emergency contact | 0..* | group | ||
| patient-contact-emergencycontact-name | Name | 0..1 | string | ||
| patient-contact-emergencycontact-phone | Phone | 0..* | string | ||
| patient-contact-emergencycontact-relationship | Personal relationship to patient (e.g. parent, child, friend) | 0..1 | string | ||
 patient-contact-additionalinformation | Additional contact information | 0..1 | text | ||
| patient-carerdetails | Carer information | 0..* | group | ||
| patient-carerinformation-hascarer | Do you have a carer? | 0..1 | choice | | Value Set: Yes/No/NA |
| patient-carerinformation-details | Details | 0..1 | text | Enable When: patient-carerinformation-hascarer = | |
| patient-carerinformation-present | Carer present at appointment | 0..1 | choice | | Enable When: patient-carerinformation-hascarer = Value Set: Yes/No/NA |
| practitioner | Practitioner details | 0..1 | group | ||
| practitioner-name | Name | 0..1 | string | | |
| practitioner-phone | Phone | 0..* | string | | |
| practitioner-email | 0..* | string | | ||
| practitioner-providernumber | Provider number | 0..* | string | | |
| clinicalhistory | Clinical history summary | 0..1 | group | ||
| clinicalhistory-problemsdiagnoses | Problems/Diagnoses | 0..* | group | ||
| clinicalhistory-problemsdiagnoses-condition | Condition | 0..1 | open-choice | | Value Set: Clinical Condition |
| clinicalhistory-problemsdiagnoses-clinicalstatus | Clinical status | 0..1 | choice | | Value Set: Condition Clinical Status Codes |
| clinicalhistory-problemsdiagnoses-onsetdate | Onset date | 0..1 | date | | |
| clinicalhistory-problemsdiagnoses-abatementdate | Abatement date | 0..1 | date | | |
| clinicalhistory-allergy | Adverse reaction risk summary | 0..* | group | ||
| clinicalhistory-allergy-substance | Substance | 0..1 | open-choice | | Value Set: Adverse Reaction Agent |
| clinicalhistory-allergy-manifestation | Manifestation | 0..* | open-choice | | Value Set: Clinical Finding |
| clinicalhistory-allergy-comment | Comment | 0..1 | text | | |
| clinicalhistory-medications | Current medications | 0..* | group | ||
| clinicalhistory-medications-medication | Medication | 0..1 | open-choice | | Value Set: Australian Medication |
| clinicalhistory-medications-dosage | Dosage | 0..1 | text | | |
| clinicalhistory-medications-clinicalindication | Clinical indication | 0..* | open-choice | | Value Set: Medication Reason Taken |
| clinicalhistory-medications-comment | Comment | 0..1 | text | | |
| clinicalhistory-observations | Observations summary | 0..1 | group | ||
| clinicalhistory-observations-maingrid | null | 0..1 | group | | |
| clinicalhistory-observations-maingrid-height | Height | 0..1 | group | ||
 clinicalhistory-observations-maingrid-height-value | Value | 0..1 | decimal | ||
| clinicalhistory-observations-maingrid-height-value-unit | cm | 0..1 | display | ||
| clinicalhistory-observations-maingrid-height-date | Date performed | 0..1 | date | ||
| clinicalhistory-observations-maingrid-weight | Weight | 0..1 | group | ||
| clinicalhistory-observations-maingrid-weight-value | Value | 0..1 | decimal | ||
| clinicalhistory-observations-maingrid-weight-value-unit | kg | 0..1 | display | ||
| clinicalhistory-observations-maingrid-weight-date | Date performed | 0..1 | date | ||
| clinicalhistory-observations-maingrid-bmi | BMI | 0..1 | group | ||
| clinicalhistory-observations-maingrid-bmi-value | Value | 0..1 | decimal | | |
| clinicalhistory-observations-maingrid-bmi-value-unit | kg/m2 | 0..1 | display | ||
| clinicalhistory-observations-maingrid-waistcircumference | Waist circumference | 0..1 | group | ||
| clinicalhistory-observations-maingrid-waistcircumference-value | Value | 0..1 | decimal | ||
| clinicalhistory-observations-maingrid-waistcircumference-value-unit | cm | 0..1 | display | ||
| clinicalhistory-observations-maingrid-waistcircumference-date | Date performed | 0..1 | date | ||
| clinicalhistory-observations-maingrid-heartrate | Heart rate | 0..1 | group | ||
| clinicalhistory-observations-maingrid-heartrate-value | Value | 0..1 | integer | ||
| clinicalhistory-observations-maingrid-heartrate-value-unit | /min | 0..1 | display | ||
| clinicalhistory-observations-maingrid-heartrate-date | Date performed | 0..1 | date | ||
| clinicalhistory-observations-maingrid-heartrhythm | Heart rhythm | 0..1 | group | ||
| clinicalhistory-observations-maingrid-heartrhythm-value | Value | 0..1 | choice | Options: 2 options | |
| clinicalhistory-observations-maingrid-heartrhythm-date | Date performed | 0..1 | date | ||
| clinicalhistory-observations-maingrid-oxygensaturation | Arterial oxygen saturation | 0..1 | group | ||
| clinicalhistory-observations-maingrid-oxygensaturation-value | Value | 0..1 | integer | ||
| clinicalhistory-observations-maingrid-oxygensaturation-value-unit | % | 0..1 | display | ||
| clinicalhistory-observations-maingrid-oxygensaturation-date | Date performed | 0..1 | date | ||
| clinicalhistory-observations-maingrid-smokingstatus | Smoking status | 0..1 | group | ||
| clinicalhistory-observations-maingrid-smokingstatus-value | Value | 0..1 | choice | Value Set: Smoking Status | |
| clinicalhistory-observations-maingrid-smokingstatus-date | Date performed | 0..1 | date | ||
| clinicalhistory-observations-bpgrid | null | 0..1 | group | | |
| clinicalhistory-observations-bpgrid-bloodpressure | Blood pressure | 0..1 | group | ||
| clinicalhistory-observations-bpgrid-bloodpressure-systolic | Systolic | 0..1 | integer | ||
| clinicalhistory-observations-bpgrid-bloodpressure-systolic-unit | mm Hg | 0..1 | display | ||
| clinicalhistory-observations-bpgrid-bloodpressure-diastolic | Diastolic | 0..1 | integer | ||
| clinicalhistory-observations-bpgrid-bloodpressure-diastolic-unit | mm Hg | 0..1 | display | ||
| clinicalhistory-observations-bpgrid-bloodpressure-date | Date performed | 0..1 | date | ||
| plandetails | Management plan details | 0..1 | group | ||
| plandetails-commenceddate | Date this management plan commenced | 0..1 | date | ||
| plandetails-inprogress | Incomplete draft management plan already exists? | 0..1 | boolean | | |
 plandetails-lastcompleteddate | Date of last completed management plan | 0..1 | dateTime | ||
| plan | Management plan | 0..1 | group | ||
| plan-chronicconditiondetails | Chronic condition details | 0..* | group | ||
| plan-chronicconditiondetails-condition | Condition | 0..1 | open-choice | Value Set: Clinical Condition | |
| plan-chronicconditiondetails-onsetdate | Onset date | 0..1 | date | ||
| plan-chronicconditiondetails-comments | Comments | 0..1 | text | ||
| plan-planitems | Plan items | 0..* | group | ||
| plan-planitems-problemneed | Problem/Need | 0..1 | open-choice | Value Set: Clinical Condition | |
| plan-planitems-details | Details | 0..* | group | ||
| plan-planitems-details-goalsetting | Goal setting | 0..1 | group | ||
| plan-planitems-details-goalsetting-goals | Goals | 0..1 | text | ||
| plan-planitems-details-goalsetting-targetdate | Target date | 0..1 | date | ||
| plan-planitems-details-interventionsactions | Interventions and actions | 0..* | group | ||
| plan-planitems-details-interventionsactions-interventionsactions | Interventions/Actions | 0..1 | open-choice | Value Set: Procedure | |
| plan-planitems-details-interventionsactions-owner | Owner | 0..1 | string | ||
| plan-planitems-details-interventionsactions-duedate | Due date | 0..1 | date | ||
| plan-planitems-details-interventionsactions-comment | Comment | 0..1 | string | ||
| plan-planitems-details-servicestreatments | Services and treatments | 0..* | group | ||
| plan-planitems-details-servicestreatments-servicestreatments | Required services and treatments | 0..1 | open-choice | Value Set: Service Type | |
| plan-planitems-details-servicestreatments-activity | Activity | 0..1 | open-choice | Value Set: Procedure | |
| plan-planitems-details-servicestreatments-provider | Provider | 0..1 | string | ||
| plan-planitems-details-servicestreatments-comment | Comment | 0..1 | string | ||
| notes | Notes | 0..1 | group | ||
| notes-additionalcomments | Additional notes or comments | 0..* | text | ||
| finalpreparations | Final preparations of management plan | 0..1 | group | ||
| finalpreparations-consent | Consent | 0..1 | group | ||
| finalpreparations-consent-sharingconsent | Consent given for sharing of information with relevant healthcare providers | 0..1 | boolean | ||
| finalpreparations-consent-planconsent | Consent given to proceed with plan after discussion of the purpose, benefits, process and costs | 0..1 | boolean | ||
| finalpreparations-review | Scheduled review date | 0..1 | date | ||
| finalpreparations-copyoffered | Patient has been offered a copy of this plan | 0..1 | choice | Options: 4 options | |
| Documentation for this format | |||||
Options Sets
Answer options for clinicalhistory-observations-maingrid-heartrhythm-value
- http://snomed.info/sct#933506231000036108 ("Regular heart rhythm")
- http://snomed.info/sct#361137007 ("Irregular heart rhythm")
Answer options for finalpreparations-copyoffered
- Yes, copy provided
- Yes, copy to be posted
- Yes, but declined
- Not offered. Plan to follow up and offer at a later date
Contained Resources
Expansion based on codesystem expandedYes-NoIndicator v2.0.0 (CodeSystem)
This value set contains 3 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 | ||
http://terminology.hl7.org/CodeSystem/v2-0532 | NA | not applicable | not applicable |