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GP Chronic Condition Management Plan template

Australian documentation guide

Build a clear record of the goals and next steps agreed with the person. Use this GPCCMP template to bring their priorities, actions, responsibilities and review arrangements together.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

A useful plan starts with what matters to the person and turns the conversation into clear, agreed actions. This template keeps their goals, responsibilities and review arrangements together.

Use the current name, GP Chronic Condition Management Plan (GPCCMP). Services Australia explains the current and legacy arrangements. The headings help organise the record; Medicare eligibility and service requirements need a separate check. Record agreement to proceed, sharing consent and a copy offer when they actually happened.

Relevant history and context

Give the next reader the background needed to understand the plan: established conditions, health needs and the person’s circumstances. Say whether you are preparing a plan or reviewing or amending an existing one, and where the information came from.

Include practical barriers discussed, such as transport, cost, work or communication needs. A reported difficulty should stay a reported difficulty rather than becoming a new diagnosis or prediction.

Current medications and allergies

Include the current medicine list and allergy history used in planning, or clearly identify the verified list held with the plan. Keep names, directions, current use and information sources where known.

Phrases such as “reports stopping”, “awaiting clarification” and “change agreed today” help explain the status. Keep missing doses or incomplete allergy information visible. An old prescription alone does not establish current use.

Patient health needs and goals

Describe the health needs identified and the goals agreed with the person. Their own words often work well: “wants to attend the community group again” is clearer than “improve function”.

Include a target or timeframe only if it was agreed. A goal suggested by a clinician but still awaiting discussion needs that label. The template supplies no blood-test target, weight goal or activity prescription.

Management actions

Make each next step concrete: the agreed action, who will take it, its status and any timing discussed. Include the person’s actions, follow-up, coordination and information provided where relevant.

“Discussed”, “agreed”, “issued” and “completed” describe different events. Keep treatment, investigations and monitoring intervals to the clinician’s stated plan.

Allied health referrals

Name the profession or service requested and how it relates to the agreed goals. Include the referral’s status, sharing consent and access arrangements where discussed.

An issued referral does not establish a booked appointment or provider acceptance. Service counts depend on the programme and actual request. The allied-health referral guide covers the separate letter body.

Review schedule

State the agreed date or interval, what the review is for and who is responsible. Show whether a booking is proposed, offered or confirmed. Keep outstanding result review separate from the next plan-review appointment.

When reviewing a plan, include progress and changes actually discussed. An old review date does not show today’s agreement. A Medicare claiming interval is not a substitute for the clinical review arrangement.

Common omissions

Look for goals the person agreed to, named action owners, medicine gaps, referral status and sharing consent. Check the review arrangement and whether a copy was offered or supplied. The plan title alone does not establish funded services.

Review before confirming

Read the goals and actions back against the discussion. Check the medicine list, referrals and dates, along with current programme requirements. Label an unfinished plan or review clearly. The clinician must review and explicitly confirm generated content; this guide does not select an MBS item or submit a claim.

Worked examples

Goals agreed around shift work and an existing diabetes care plan

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

RELEVANT HISTORY & CONTEXT: Fictional in-person planning visit for a person with type 2 diabetes recorded in the practice record. Person works variable shifts and wants help fitting their existing care into that routine. GP explains the planning process; person agrees to proceed. Person is offered a copy of the agreed plan, and a copy is added to the fictional medical record.
CURRENT MEDICATIONS & ALLERGIES: Person reports taking metformin; the current prescription and directions are recorded in the separate verified medicine list supplied with the plan. No medicine change is agreed today. Person reports no known medicine allergy; the source of that report is retained.
PATIENT HEALTH NEEDS & GOALS: Person's stated goal is to prepare an evening meal at home on three workdays each week. GP and person agree to review how manageable this is at follow-up. Existing diabetes monitoring needs are recorded in the accompanying clinical assessment, not invented by this scaffold.
MANAGEMENT ACTIONS: Person will bring their work roster and meal record to the dietitian appointment. GP will discuss the existing investigation results at the agreed review. Practice nurse will help coordinate the appointments with the person's permission. These are the actions agreed in this fictional encounter.
ALLIED HEALTH REFERRALS: GP issues a dietitian referral to discuss meal planning within the person's goals. Person agrees to share relevant plan information with the nominated service. No appointment or acceptance by the dietitian is yet confirmed; programme eligibility and referral details are checked separately.
REVIEW SCHEDULE: Person and GP agree to a review in six weeks to discuss goal progress, appointment access and outstanding results. Reception will offer a booking; the appointment is not yet booked.

A review with a referral still under discussion

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

RELEVANT HISTORY & CONTEXT: Fictional review of a previously documented plan for knee osteoarthritis. Person reports that transport difficulties prevented the planned physiotherapy attendance. Person agrees to review the plan; the previous plan and current concerns are discussed.
CURRENT MEDICATIONS & ALLERGIES: Person says the medicine list has changed since the previous plan. The updated list and allergy history are not established in this extract and remain for clarification.
PATIENT HEALTH NEEDS & GOALS: Person wants to return to their weekly community group. Progress toward the earlier walking goal is not measured during this extract.
MANAGEMENT ACTIONS: GP and person agree to investigate a more accessible service. No exercise prescription, medicine change or new clinical target is documented here.
ALLIED HEALTH REFERRALS: A closer physiotherapy service is discussed. No referral is issued and consent to share information with a new service has not yet been obtained.
REVIEW SCHEDULE: A new review date, copy offer and amended-plan distribution have not been recorded. This is an incomplete review draft needing confirmation, not a completed programme service.

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.