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

## 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

Profiles: Advanced Rendering Questionnaire, Populatable Questionnaire - Expression

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 | 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 | 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 |  |