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
Example QuestionnaireResponse: QuestionnaireResponse - GP Chronic Care Form
Profile: GP CCMP QuestionnaireResponse
| LinkID | Text | Definition | Answer |
|---|---|---|---|
  gpccmp-form-foreman-caterina | Questionnaire:GP Chronic Condition Management Plan | ||
  container | |||
  patient | Patient details | ||
 patient-consent | Consent | ||
 patient-consent-consentforplan | Consent given to proceed with plan after discussion of the purpose, benefits, process and costs | true | |
| patient-name | Name | Caterina FOREMAN | |
| patient-preferredpronouns | Preferred pronouns | LOINC: LA29519-8 (she/her/her/hers/herself) | |
| patient-dob | Date of birth | 1970-07-24 | |
| patient-age | Age | 55 | |
| patient-sexatbirth | Sex assigned at birth | SNOMED CT: 248152002 (Female) | |
| patient-genderidentity | Gender identity | SNOMED CT: 446141000124107 (Identifies as female gender) | |
| patient-firstnationsstatus | Aboriginal and/or Torres Strait Islander status | australian-indigenous-status-1: 4 (Neither Aboriginal nor Torres Strait Islander origin) | |
| patient-medicare | Medicare card number | ||
| patient-medicare-number | Number | 3951333701 | |
| patient-medicare-referencenumber | Reference number | 1 | |
| patient-medicare-expiry | Expiry | 2028-08 | |
| patient-contact | Contact information | ||
| patient-contact-homephone | Home phone | 0370109077 | |
| patient-contact-mobilephone | Mobile phone | 0491576801 | |
| patient-contact-email | caterina.foreman@my-own-personal-domain.com | ||
| patient-contact-homeaddress | Home address | ||
| patient-contact-homeaddress-details | Home address | ||
| patient-contact-homeaddress-details-streetaddress | Street address | 149 Farmer Cnr | |
| patient-contact-homeaddress-details-city | City | Sunshine | |
| patient-contact-homeaddress-details-state | State | australian-states-territories-1: VIC (Victoria) | |
| patient-contact-homeaddress-details-postcode | Postcode | 3020 | |
| practitioner | Practitioner details | ||
| practitioner-name | Name | Peter Primary | |
| practitioner-phone | Phone | (08) 7010 5556 | |
| practitioner-email | PPP@example.org | ||
| practitioner-medicareprovidernumber | Medicare provider number | 2426621B | |
| clinicaldetails | Clinical details | ||
| clinicaldetails-problemsdiagnoses | Problems/Diagnoses | ||
| clinicaldetails-problemsdiagnoses-recordedproblems | Recorded problems/diagnoses | ||
| clinicaldetails-problemsdiagnoses-recordedproblems-condition | Condition | SNOMED CT: 278860009 (Chronic lower back pain) | |
| clinicaldetails-problemsdiagnoses-recordedproblems-clinicalstatus | Clinical status | Condition Clinical Status Codes: active (Active) | |
| clinicaldetails-problemsdiagnoses-recordedproblems-onsetdate | Onset date | 2021-01-01 | |
| clinicaldetails-problemsdiagnoses-recordedproblems | Recorded problems/diagnoses | ||
| clinicaldetails-problemsdiagnoses-recordedproblems-condition | Condition | SNOMED CT: 235595009 (Gastro-oesophageal reflux disease) | |
| clinicaldetails-problemsdiagnoses-recordedproblems-clinicalstatus | Clinical status | Condition Clinical Status Codes: active (Active) | |
| clinicaldetails-problemsdiagnoses-recordedproblems-onsetdate | Onset date | 2013-08-01 | |
| clinicaldetails-problemsdiagnoses-newproblems | New problems/diagnoses | ||
| clinicaldetails-problemsdiagnoses-newproblems-condition | Condition | SNOMED CT: 443694000 (Type 2 diabetes mellitus uncontrolled) | |
| clinicaldetails-problemsdiagnoses-newproblems-onsetdate | Onset date | 2026-01-25 | |
| clinicaldetails-problemsdiagnoses-newproblems | New problems/diagnoses | ||
| clinicaldetails-problemsdiagnoses-newproblems-condition | Condition | SNOMED CT: 424736006 (Diabetic peripheral neuropathy) | |
| clinicaldetails-problemsdiagnoses-newproblems-onsetdate | Onset date | 2026-02-20 | |
| clinicaldetails-problemsdiagnoses-newproblems | New problems/diagnoses | ||
| clinicaldetails-problemsdiagnoses-newproblems-condition | Condition | SNOMED CT: 238131007 (Overweight) | |
| clinicaldetails-problemsdiagnoses-newproblems-onsetdate | Onset date | 2025-11-25 | |
| clinicaldetails-allergies | Adverse reaction risks | ||
| clinicaldetails-allergies-recordedallergies | Recorded adverse reaction risks | ||
| clinicaldetails-allergies-recordedallergies-substance | Substance | SNOMED CT: 111088007 (Latex) | |
| clinicaldetails-allergies-recordedallergies-status | Status | AllergyIntolerance Clinical Status Codes: active (Active) | |
| clinicaldetails-allergies-recordedallergies-manifestation | Manifestation | SNOMED CT: 271807003 (Rash) | |
| clinicaldetails-allergies-recordedallergies-comment | Comment | Has reacted soon after exposure as well as a delayed reaction to latex, with a rash appearing 24 hours after exposure. | |
| clinicaldetails-medications | Medications (current) | ||
| clinicaldetails-medications-recordedmedications | Recorded medications | ||
| clinicaldetails-medications-recordedmedications-medication | Medication | SNOMED CT: 5848011000036106 (Panadol Osteo 665 mg modified release tablet) | |
| clinicaldetails-medications-recordedmedications-status | Status | Medication status codes: active (Active) | |
| clinicaldetails-medications-recordedmedications-dosage | Dosage | 2 tabs PRN/TDS | |
| clinicaldetails-medications-recordedmedications-indication | Indication | SNOMED CT: 278860009 (Chronic lower back pain) | |
| clinicaldetails-medications-recordedmedications | Recorded medications | ||
| clinicaldetails-medications-recordedmedications-medication | Medication | SNOMED CT: 5848011000036106 (Panadol Osteo 665 mg modified release tablet) | |
| clinicaldetails-medications-recordedmedications-status | Status | Medication status codes: active (Active) | |
| clinicaldetails-medications-recordedmedications-dosage | Dosage | 2 tabs PRN/TDS | |
| clinicaldetails-medications-recordedmedications-indication | Indication | SNOMED CT: 278860009 (Chronic lower back pain) | |
| clinicaldetails-medications-recordedmedications | Recorded medications | ||
| clinicaldetails-medications-recordedmedications-medication | Medication | SNOMED CT: 682641000168107 (Esomeprazole 20 mg enteric capsule) | |
| clinicaldetails-medications-recordedmedications-status | Status | Medication status codes: active (Active) | |
| clinicaldetails-medications-recordedmedications-dosage | Dosage | 1 tab daily | |
| clinicaldetails-medications-recordedmedications-indication | Indication | SNOMED CT: 235595009 (Gastro-oesophageal reflux disease) | |
| clinicaldetails-medications-recordedmedications-comment | Comment | Gastroscopy 2013 - mild reflux esophagitis, H pylori negative | |
| clinicaldetails-medications-newmedications | New medications | ||
| clinicaldetails-medications-newmedications-medication | Medication | SNOMED CT: 23358011000036102 (Metformin hydrochloride 500 mg tablet) | |
| clinicaldetails-medications-newmedications-dosage | Dosage | 1 tab BD | |
| clinicaldetails-medications-newmedications-indication | Indication | SNOMED CT: 443694000 (Type 2 diabetes mellitus uncontrolled) | |
| clinicaldetails-medications-newmedications | New medications | ||
| clinicaldetails-medications-newmedications-medication | Medication | SNOMED CT: 77436011000036106 (Fish oil) | |
| clinicaldetails-medications-newmedications-dosage | Dosage | 2 caps daily | |
| clinicaldetails-medications-newmedications-comment | Comment | Self-initiated for heart health | |
| clinicaldetails-observations | Observations | ||
| clinicaldetails-observations-maingrid | Observations | ||
| clinicaldetails-observations-maingrid-height | Height | ||
| clinicaldetails-observations-maingrid-height-lastresultvalue | 165 | ||
| clinicaldetails-observations-maingrid-height-lastresultdate | 2025-11-25 | ||
| clinicaldetails-observations-maingrid-height-newresultvalue | New result | 165 | |
| clinicaldetails-observations-maingrid-height-newresultdate | New result date | 2026-03-09 | |
| clinicaldetails-observations-maingrid-weight | Weight | ||
| clinicaldetails-observations-maingrid-weight-lastresultvalue | 74 | ||
| clinicaldetails-observations-maingrid-weight-lastresultdate | 2025-11-25 | ||
| clinicaldetails-observations-maingrid-weight-newresultvalue | New result | 75.2 | |
| clinicaldetails-observations-maingrid-weight-newresultdate | New result date | 2026-03-09 | |
| clinicaldetails-observations-maingrid-bmi | BMI (calculated) | ||
| clinicaldetails-observations-maingrid-bmi-lastresultvalue | 27.2 | ||
| clinicaldetails-observations-maingrid-bmi-newresultvalue | New result | 27.6 | |
| clinicaldetails-observations-maingrid-waistcircumference | Waist circumference | ||
| clinicaldetails-observations-maingrid-waistcircumference-lastresultvalue | 82 | ||
| clinicaldetails-observations-maingrid-waistcircumference-lastresultdate | 2025-11-25 | ||
| clinicaldetails-observations-maingrid-waistcircumference-newresultvalue | New result | 82.5 | |
| clinicaldetails-observations-maingrid-waistcircumference-newdate | New result date | 2026-03-09 | |
| clinicaldetails-observations-maingrid-pulserate | Pulse rate | ||
| clinicaldetails-observations-maingrid-pulserate-lastresultvalue | 74 | ||
| clinicaldetails-observations-maingrid-pulserate-lastresultdate | 2025-11-25 | ||
| clinicaldetails-observations-maingrid-pulserate-newresultvalue | New result | 76 | |
| clinicaldetails-observations-maingrid-pulserate-newresultdate | New result date | 2026-03-09 | |
| clinicaldetails-observations-maingrid-pulserhythm | Pulse rhythm | ||
| clinicaldetails-observations-maingrid-pulserhythm-lastresultvalue | SNOMED CT: 271636001 (Pulse regular) | ||
| clinicaldetails-observations-maingrid-pulserhythm-lastresultdate | 2025-11-25 | ||
| clinicaldetails-observations-maingrid-pulserhythm-newresultvalue | New result | SNOMED CT: 271636001 (Pulse regular) | |
| clinicaldetails-observations-maingrid-pulserhythm-newresultdate | New result date | 2026-03-09 | |
| clinicaldetails-observations-maingrid-oxygensaturation | Oxygen saturation | ||
| clinicaldetails-observations-maingrid-oxygensaturation-lastresultvalue | 98 | ||
| clinicaldetails-observations-maingrid-oxygensaturation-lastresultdate | 2026-06-20 | ||
| clinicaldetails-observations-maingrid-oxygensaturation-newresultvalue | New result | 98 | |
| clinicaldetails-observations-maingrid-oxygensaturation-newresultdate | New result date | 2026-03-09 | |
| clinicaldetails-observations-bpgrid | Blood pressure | ||
| clinicaldetails-observations-bpgrid-bp | Blood pressure | ||
| clinicaldetails-observations-bpgrid-bp-lastresultvaluesystolic | 128 | ||
| clinicaldetails-observations-bpgrid-bp-lastresultvaluediastolic | 72 | ||
| clinicaldetails-observations-bpgrid-bp-lastresultdate | 2025-11-25 | ||
| clinicaldetails-observations-bpgrid-bp-newresultsystolic | Systolic | 130 | |
| clinicaldetails-observations-bpgrid-bp-newresultdiastolic | Diastolic | 72 | |
| clinicaldetails-observations-bpgrid-bp-newresultdate | Date performed | 2026-03-09 | |
| clinicaldetails-observations-substanceusegrid | Substance use | ||
| clinicaldetails-observations-substanceusegrid-smokingstatus | Smoking status | ||
| clinicaldetails-observations-substanceusegrid-smokingstatus-lastresultvalue | SNOMED CT: 77176002 (Current smoker) | ||
| clinicaldetails-observations-substanceusegrid-smokingstatus-lastresultdate | 2026-02-20 | ||
| clinicaldetails-observations-substanceusegrid-smokingstatus-newresultdate | New status date | null! | |
| clinicaldetails-observations-smokingstatusgrid-smokingstatus-newresultcomment | Comment | Smoking - 20 cigarettes per day since 17yo | |
| clinicaldetails-observations-substanceusegrid-alcoholstatus | Alcohol consumption status | ||
| clinicaldetails-observations-substanceusegrid-alcoholstatus-lastresultvalue | SNOMED CT: 219006 (Current drinker) | ||
| clinicaldetails-observations-substanceusegrid-alcoholstatus-lastresultdate | 2026-02-20 | ||
| clinicaldetails-observations-substanceusegrid-alcoholstatus-newresultdate | New status date | null! | |
| clinicaldetails-observations-substanceusegrid-alcoholstatus-newresultcomment | Comment | 2 drinks, 2 days per week (on weekends | |
| plan | Plan | ||
| plandetails-commenceddate | Date this plan commenced | 2026-02-20 | |
| plandetails-inprogress | Incomplete draft plan already exists? | true | |
| plan-conditions | Conditions addressed | ||
| plan-conditions-condition | Condition | SNOMED CT: 443694000 (Type 2 diabetes mellitus uncontrolled) | |
| plan-conditions-onsetdate | Onset date | 2026-01-25 | |
| plan-conditions | Conditions addressed | ||
| plan-conditions-condition | Condition | SNOMED CT: 278860009 (Chronic lower back pain) | |
| plan-conditions-onsetdate | Onset date | 2021-01-01 | |
| plan-conditions | Conditions addressed | ||
| plan-conditions-condition | Condition | SNOMED CT: 235595009 (Gastro-oesophageal reflux disease) | |
| plan-conditions-onsetdate | Onset date | 2013-08-01 | |
| plan-conditions | Conditions addressed | ||
| plan-conditions-condition | Condition | SNOMED CT: 238131007 (Overweight) | |
| plan-conditions-onsetdate | Onset date | 2025-11-25 | |
| plan-goalstasks | Goals and tasks | ||
| plan-goalstasks-problemneed | Problems/Needs | ||
| plan-goalstasks-details-goalsetting | Goal setting | ||
| plan-goalstasks-details-goalsetting-goals | Goals | 5-10% weight loss (target weight 73.8-77.9kg) and decrease waist circumference (long term target <80cm) | |
| plan-goalstasks-details-goalsetting-initiator | Initiator | GP | |
| plan-goalstasks-details-goalsetting-targetdate | Target date | 2027-02-24 | |
| plan-goalstasks-details-goalsetting-status | Status | GoalLifecycleStatus: active (active) | |
| plan-goalstasks-details-interventionsactions | Interventions and actions | ||
| plan-goalstasks-details-interventionsactions-interventionsactions | Interventions/Actions | SNOMED CT: 183065007 (Low carbohydrate diet education) | |
| plan-goalstasks-details-interventionsactions-owner | Owner | Caterina, dietitian | |
| plan-goalstasks-details-interventionsactions-duedate | Due date | 2026-05-24 | |
| plan-goalstasks-details-interventionsactions | Interventions and actions | ||
| plan-goalstasks-details-interventionsactions-interventionsactions | Interventions/Actions | Reduce ratio of carbohydrates in each meal - ¼ plate carbs, ¼ plate protein, ½ plate vegetables/salad | |
| plan-goalstasks-details-interventionsactions-owner | Owner | Caterina | |
| plan-goalstasks-details-interventionsactions-duedate | Due date | 2026-05-24 | |
| plan-goalstasks-details-interventionsactions | Interventions and actions | ||
| plan-goalstasks-details-interventionsactions-interventionsactions | Interventions/Actions | Substitute high GI for low GI carbohydrates where possible | |
| plan-goalstasks-details-interventionsactions-owner | Owner | Caterina | |
| plan-goalstasks-details-interventionsactions-duedate | Due date | 2026-05-24 | |
| plan-goalstasks-details-interventionsactions | Interventions and actions | ||
| plan-goalstasks-details-interventionsactions-interventionsactions | Interventions/Actions | Physical activity guidance | |
| plan-goalstasks-details-interventionsactions-owner | Owner | Caterina, exercise physiologist | |
| plan-goalstasks-details-interventionsactions-duedate | Due date | 2026-08-24 | |
| plan-goalstasks-details-interventionsactions | Interventions and actions | ||
| plan-goalstasks-details-interventionsactions-interventionsactions | Interventions/Actions | Aim for 150 mins of aerobic activity per week | |
| plan-goalstasks-details-interventionsactions-owner | Owner | Caterina | |
| plan-goalstasks-details-interventionsactions-duedate | Due date | 2026-08-24 | |
| plan-goalstasks-details-interventionsactions | Interventions and actions | ||
| plan-goalstasks-details-interventionsactions-interventionsactions | Interventions/Actions | 2-3 sessions of resistance exercise per week | |
| plan-goalstasks-details-interventionsactions-owner | Owner | Caterina | |
| plan-goalstasks-details-interventionsactions-duedate | Due date | 2026-08-24 | |
| plan-goalstasks-details-interventionsactions | Interventions and actions | ||
| plan-goalstasks-details-interventionsactions-interventionsactions | Interventions/Actions | Management of impulse control | |
| plan-goalstasks-details-interventionsactions-owner | Owner | Caterina | |
| plan-goalstasks-details-interventionsactions-duedate | Due date | 2026-08-24 | |
| plan-goalstasks-details-interventionsactions-comment | Comment | Manage impulsivity/desire to eat when not actually hungry. Consider psychology input in future. | |
| plan-goalstasks-details-servicestreatments | Services and treatments | ||
| plan-goalstasks-details-servicestreatments-servicestreatments | Required services and treatments | SNOMED CT: 310090003 (Dietetics service) | |
| plan-goalstasks-details-servicestreatments-activity | Activity | SNOMED CT: 103699006 (Referral to dietitian) | |
| plan-goalstasks-details-servicestreatments-provider | Provider | Dietitian | |
| plan-goalstasks-details-servicestreatments | Services and treatments | ||
| plan-goalstasks-details-servicestreatments-servicestreatments | Required services and treatments | SNOMED CT: 310090003 (Dietetics service) | |
| plan-goalstasks-details-servicestreatments-activity | Activity | SNOMED CT: 11816003 (Diet education) | |
| plan-goalstasks-details-servicestreatments-provider | Provider | Dietitian | |
| plan-goalstasks-details-servicestreatments | Services and treatments | ||
| plan-goalstasks-details-servicestreatments-servicestreatments | Required services and treatments | Exercise physiologist | |
| plan-goalstasks-details-servicestreatments-activity | Activity | SNOMED CT: 1100681000168103 (Referral to exercise physiologist) | |
| plan-goalstasks-details-servicestreatments-provider | Provider | Exercise physiologist | |
| plan-goalstasks-details-servicestreatments | Services and treatments | ||
| plan-goalstasks-details-servicestreatments-servicestreatments | Required services and treatments | Exercise physiologist | |
| plan-goalstasks-details-servicestreatments-activity | Activity | SNOMED CT: 229080003 (Exercise regime) | |
| plan-goalstasks-details-servicestreatments-provider | Provider | Exercise physiologist | |
| plan-goalstasks | Goals and tasks | ||
| plan-goalstasks-problemneed | Problems/Needs | ||
| plan-goalstasks-details-goalsetting | Goal setting | ||
| plan-goalstasks-details-goalsetting-goals | Goals | Comfortably wear dress purchased for niece’s wedding next year | |
| plan-goalstasks-details-goalsetting-initiator | Initiator | Caterina | |
| plan-goalstasks-details-goalsetting-targetdate | Target date | 2027-02-24 | |
| plan-goalstasks-details-goalsetting-status | Status | GoalLifecycleStatus: active (active) | |
| completion | Completion | ||
| completion-consentforsharing | Consent given for sharing of information with relevant healthcare providers | true | |
| completion-review | Review | ||
| completion-review-appointmentstatus | Appointment status | AppointmentStatus: proposed (Proposed) | |
| completion-review-date | Date | 2027-03-09 | |
| completion-copyoffered | Patient has been offered a copy of this plan | Yes, copy provided | |
| Documentation for this format | |||