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