GP Chronic Condition Management Plan
0.1.0 - CI Build
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
Patient: Caterina FOREMAN
Author: Dr Peter Primary
Date Authored: 17/08/2026 11:36
Consent given to proceed with plan after discussion of the purpose, benefits, process and costs
Yes
Name
Caterina FOREMAN
Preferred pronouns
she/her/her/hers/herself
Date of birth
24/07/1970
Age
55
Sex assigned at birth
Female
Gender identity
Identifies as female gender
Aboriginal and/or Torres Strait Islander status
Neither Aboriginal nor Torres Strait Islander origin
Registered for My Aged Care
No
Registered for NDIS
No
| Number | Reference number | Expiry |
|---|---|---|
| 3951333701 | 1 | 2028-08 |
| Street address | City | State | Postcode |
|---|---|---|---|
| 149 Farmer Cnr | Sunshine | Victoria | 3020 |
| Preferred contact | Role | Name | Phone | Relationship to patient | Present at appointment | |
|---|---|---|---|---|---|---|
| Yes | Contact person Carer | Mia LEANNE BANKS | 0270107520 0491574632 0270102724 | |||
| Emergency Contact | Heather MACKAY | 0370108075 0491578148 0370103228 |
Name
Peter Primary
Name
Quinninup Medical Clinic
Street address
24 Grande Pl
City
Quinninup
State
Western Australia
Postcode
6258
| Condition | Clinical status | Onset date | Abatement date |
|---|---|---|---|
| Chronic lower back pain | Active | 01/01/2021 | |
| Gastro-oesophageal reflux disease | Active | 01/08/2013 |
| Condition | Onset date | Comment |
|---|---|---|
| Uncontrolled type 2 diabetes | 25/01/2026 | |
| Peripheral neuropathy due to diabetes | 20/02/2026 | |
| Overweight | 25/11/2025 |
| Substance | Status | Manifestation | Comment |
|---|---|---|---|
| Latex | Active | Rash | Has reacted soon after exposure as well as a delayed reaction to latex, with a rash appearing 24 hours after exposure. |
| Medication | Status | Dosage | Indication | Comment |
|---|---|---|---|---|
| Panadol Osteo 665 mg modified release tablet | Active | 2 tabs PRN/TDS | Chronic lower back pain | |
| Panadol Osteo 665 mg modified release tablet | Active | 2 tabs PRN/TDS | Chronic lower back pain | |
| Esomeprazole 20 mg enteric capsule | Active | 1 tab daily | Gastro-oesophageal reflux disease | Gastroscopy 2013 - mild reflux esophagitis, H pylori negative |
| Medication | Dosage | Indication | Comment |
|---|---|---|---|
| Metformin hydrochloride 500 mg tablet | 1 tab BD | Uncontrolled type 2 diabetes | |
| Fish oil | 2 caps daily | Self-initiated for heart health |
New result
165 cm
New result date
17/08/2026
New result
75.2 kg
New result date
17/08/2026
New result
27.6 kg/m2
New result
82.5 cm
New result date
17/08/2026
New result
76 /min
New result date
17/08/2026
New result
Pulse regular
New result date
17/08/2026
New result
98 %
New result date
17/08/2026
Systolic
130 mm[Hg]
Diastolic
72 mm[Hg]
Date performed
17/08/2026
Comment
20 cigarettes per day since 17yo
Comment
2 drinks, 2 days per week (on weekends)
Additional information
Family history: Mother - diabetes, stroke; Father - heart attack, depression; Paternal grandmother - breast cancer
Work: Receptionist in building business
New plan or a review of an existing plan?
New
Incomplete draft plan already exists?
Yes
| Condition | Onset date | Comments |
|---|---|---|
| Uncontrolled type 2 diabetes | 25/01/2026 | |
| Chronic lower back pain | 01/01/2021 | |
| Gastro-oesophageal reflux disease | 01/08/2013 | |
| Overweight | 25/11/2025 |
| Goals | Initiator | Target date | Status | Comment |
|---|---|---|---|---|
| Controlled diabetes - aim HbA1c ≤7.0 and fasting BGL 4.0-7.0 | GP | 20/05/2027 | active |
| Interventions/Actions | Owner | Target date | Status | Comment |
|---|---|---|---|---|
| Diabetic education | Caterina, diabetes educator | 20/08/2026 | Planned | |
| Diet education | Caterina, dietitian | 20/08/2026 | Planned | |
| Exercise regime | Caterina, exercise physiologist | 20/11/2026 | Planned | Aim for 150 mins moderate physical activity per week |
| Weight management program | Caterina, GP | 20/05/2027 | Planned | Aim for 5-10% weight loss, waist circumference <80cm |
| Diabetes medicine review | Caterina, GP, pharmacist | 20/08/2026 | Planned | Consider Home Medicines Review in 3-6 months |
| Metformin therapy | Caterina, GP, pharmacist | 03/06/2026 | Planned | |
| Detecting complications early | Caterina, GP, podiatrist, optometrist | 20/05/2027 | Planned | Regular screening for diabetic nephropathy, neuropathy and retinopathy |
| Required services and treatments | Activity | Provider | Comment |
|---|---|---|---|
| Diabetes education service | Referral to diabetes nurse | Diabetes educator | |
| Diabetes education service | Diabetes diet education | Diabetes educator | |
| Dietetics service | Referral to dietitian | Dietitian | |
| Dietetics service | Diet education | Dietitian | |
| Exercise physiology service | Referral to exercise physiologist | Exercise physiologist | |
| Exercise physiology service | Exercise regime | Exercise physiologist | |
| Medicine review service | Referral to pharmacist | Pharmacist | |
| Medicine review service | Home medicines review | Pharmacist | Consider Home Medicines Review in 3-6 months |
| General practice service | Ongoing review | GP, practice nurse |
| Goals | Initiator | Target date | Status | Comment |
|---|---|---|---|---|
| 5-10% weight loss (target weight 73.8-77.9kg) and decrease waist circumference (long term target <80cm) | GP | 20/05/2027 | active | |
| Comfortably wear dress purchased for niece’s wedding next year | Caterina | 20/05/2027 | active |
| Interventions/Actions | Owner | Target date | Status | Comment |
|---|---|---|---|---|
| Low carbohydrate diet education | Caterina, dietitian | 20/08/2026 | Planned | |
| Reduce ratio of carbohydrates in each meal – ¼ plate carbs, ¼ plate protein, ½ plate vegetables/salad | Caterina | 20/08/2026 | Planned | |
| Substitute high GI for low GI carbohydrates where possible | Caterina | 20/08/2026 | Planned | |
| Physical activity guidance | Caterina, exercise physiologist | 20/11/2026 | Planned | |
| Aim for 150 mins of aerobic activity per week | Caterina | 20/11/2026 | Planned | |
| 2-3 sessions of resistance exercise per week | Caterina | 20/11/2026 | Planned | |
| Management of impulse control | Caterina | 20/11/2026 | Planned | Manage impulsivity/desire to eat when not actually hungry. Consider psychology input in future |
| Required services and treatments | Activity | Provider | Comment |
|---|---|---|---|
| Dietetics service | Referral to dietitian | Dietitian | |
| Dietetics service | Diet education | Dietitian | |
| Exercise physiology service | Referral to exercise physiologist | Exercise physiologist | |
| Exercise physiology service | Exercise regime | Exercise physiologist |
Consent given for sharing of information with relevant healthcare providers
Yes
Appointment status
Proposed
Date
20/05/2027