Care Plan & Referral Template For Individual Allied Health Services Under Medicare Page 2
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4MEDICAL HISTORY
Ischaemic Heart Disease
Osteoarthritis
Type 2 diabetes
Osteoporosis
Hypercholesterolaemia /
Depression
Dyslipidaemia
Other:
Hypertension
Allergies:
Medications:
If the patient has a previous or existing care plan, when was it prepared and what were
the outcomes:
Other notes or comments relevant to the patient’s care planning:
GPMP & TCA (Item 721 & 723)
REVIEW
NEED
GOAL
ACTIONS
PROVIDERS
DATE
Aim for HBA1c
Meal plan; Regular meals;
Maintain or
GP
< ______%
Low fat & Low GI; Reduce
3-6 months
improve
AEP
Maintain blood
Alcohol; Regular Home
blood
Dietitian
sugars near
Monitoring; Exercise
sugars
Diabetes
normal range
program prescribed by AEP
educator
Normal range = 3
– 8 mmol/ls
Aim for
Increase physical activity
Weight
GP
BMI
Appropriate diet
3-6 months
managemen
AEP
< _______
t
Dietitian
Aim for:
Review physical activity
If normal,
Control
GP
Total chol < 5
levels & eating habits
every 1-2 yrs;
cholesterol
AEP
LDL chol < 3
Review medications
If abnormal,
Dietitian
HDL chol > 1
Regular blood tests
every 3-6
Triglycerides < 2
months
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