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{\footer\pard\s16\plain\f0\fs16\i Original template compiled by Monash Division of General Practice, December 2006\par}\pard\s16\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Miscellaneous:Practice Letterhead>>{\*\txfieldend}\plain\f1\fs24\par\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt40\trpaddr30\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw20\clcbpat5\cellx9638\pard\widctlpar\intbl\pard\intbl\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b GP MANAGEMENT PLAN \plain\f1\fs24\b\cb3\chshdng0\chcfpat0\chcbpat3 - MBS ITEM No 721 \plain\f1\fs24\b (Palliative Care) \plain\f1\fs24\cb4\chshdng0\chcfpat0\chcbpat4\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b Patient\loch\f1\hich\f1 \'92s Name:\plain\f1\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f1\fs24\cell\plain\f1\fs20\b Date of Birth:\plain\f1\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:DOB>>{\*\txfieldend}\plain\f1\fs24\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Contact Details:\plain\f1\fs20\tab\plain\f1\fs20\b\cell Medicare or Private Health Insurance Details:\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Full Address>>{\*\txfieldend}\plain\f1\fs20\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Medicare Number>>{\*\txfieldend}\plain\f1\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Health Insurance>>{\*\txfieldend}\plain\f1\fs20\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b Details of Patient\loch\f1\hich\f1 \'92s Usual GP:\plain\f1\fs20\cell\plain\f1\fs20\b Details of Patient\loch\f1\hich\f1 \'92s Carer (if applicable):\plain\f1\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Name>>{\*\txfieldend}\plain\f1\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Full Address>>{\*\txfieldend}\plain\f1\fs20\cell\par\par\par\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f1\fs20\b Date of last Care Plan/GP Management Plan (if done):\plain\f1\fs20   {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0044007c007c007c00310030007c00200020002f00200020002f0020002000200020000000}{\*\txfieldtext \plain\f1\fs20 <<Date of last Care Plan/GPMP>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|D|||10|  /  /    "}}{\fldrslt{\plain\f1\fs20 <<Date of last Care Plan/GPMP>>}}}}\plain\f1\fs20\par\par\plain\f1\fs20\b Other notes or comments relevant to the patient\loch\f1\hich\f1 \'92s management plan:\plain\f1\fs24  \plain\f1\fs20\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f1\fs20\b PAST MEDICAL HISTORY\par\plain\f1\fs20\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 41000000}{\*\txfieldtext \plain\f1\fs20 <<Clinical Details:History List>>}{\field{\*\fldinst { HYPERLINK "A" }}{\fldrslt{\plain\f1\fs20 <<Clinical Details:History List>>}}}}\plain\f1\fs20\b\par\par FAMILY HISTORY\par\plain\f1\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Clinical Details:Family History>>{\*\txfieldend}\plain\f1\fs20\b\par\par MEDICATIONS \par\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Clinical Details:Medication List>>{\*\txfieldend}\plain\f1\fs24\par\par\plain\f1\fs20\b ALLERGIES\par\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 0000}{\*\txfieldtext \plain\f1\fs20 <<Clinical Details:Allergies>>}}\plain\f1\fs20\b\par\page Patient\loch\f1\hich\f1 \'92s Name: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f1\fs24\par\plain\f1\fs20\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx9638\pard\widctlpar\intbl\pard\s2\intbl\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs24\b\cb3\chshdng0\chcfpat0\chcbpat3 GP MANAGEMENT PLAN \loch\f0\hich\f0 \'96 PALLIATIVE CARE (MBS ITEM 721)\plain\f0\fs20\b\cb3\chshdng0\chcfpat0\chcbpat3\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs2\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20\b Patient problems / needs / relevant conditions\plain\f1\fs20\cell\plain\f0\fs20\b Goals - changes to be achieved\plain\f1\fs20\cell\plain\f0\fs20\b Required treatments and services including patient actions\plain\f1\fs20\cell\plain\f0\fs20\b Arrangements for treatments/services (when, who, and contact details)\plain\f1\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b 1. Participation of patient in decision making\cell\plain\f1\fs20 Open communication between patient, family, GP and health care professionals.\cell\pard\s17\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Patient and/ family actively participate in treatment decisions.\par\par Advance care planning.\cell\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 GP\par Patient \par Family\par Health care professionals\par Solicitor\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\s1\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b 2. Pain management\cell\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Optimal pain management.\par\par\par\pard\intbl\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800 Ensure a good nights sleep.\cell\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Diagnose and treat the cause of the pain. \par\par Medication management.\cell GP\par Specialist\par Community Nurse\par Patient / family\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\s17\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b 3. Symptom control:\cell\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\cell\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Constipation \par Incontinence\par\cell Manage symptoms.\par\par Keep comfortable\cell Discuss treatment options with patient\par\cell GP\par Patient / Family\par Community Nurse\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Nausea\par Vomiting\par Dry mouth\par\par\cell Manage symptoms.\par\par Keep comfortable\cell - Diet and fluids as per patient and family wishes\par - Diligent mouth care, monitor for oral infections/thrush. Treat as required.\par - Ice to suck.\par - Medication management\cell GP\par Patient\par Family\par Community Nurse\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Shortness of breath\par\par\cell Manage symptoms\par\par Keep comfortable\cell - Pain management\par - Oxygen therapy as required.\par - Relaxation techniques.\par - Fan, open window.\par - Find optimal position to aid breathing for patient.\cell GP\par Patient\par Family\par Community Nurse\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Fatigue\par\cell Help with day to day care\cell Care giver for day-to-day needs.\par Home help\cell GP\par Patient /family\par Carer\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Skin care\par\cell Prevent and/ treat pressure sores.\par\par Maintain comfort.\par\cell Care of high risk patient:\par\pard\intbl\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800 - change position frequently\par - keep skin clean and dry\par - lotions as needed\par - treat any bed sores\par - exercise arms/legs as tolerated\cell\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 GP\par Patient/family\par Community Nurse\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b 4. Psychological support\par\plain\f1\fs20\cell Support for patient and family\cell - Help patient and family to manage anxiety, anger, depression, and /frustration. \par - Medication management \cell GP \par Counsellor\par Psychologist\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b 5. Religious / spiritual support\cell\plain\f1\fs20 Patient / family receive support required\cell Access to support\cell Religious adviser\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b 6. Social support\cell\plain\f1\fs20 Organise support services to assist patient / family\cell Home help\par Shopping\par Respite\par\par\cell GP\par Community nurse\par Local Council\par Home help\par Other community services\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2410\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4820\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9639\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b 7. Medication Management\cell\plain\f1\fs20 Protocol for medication management\cell On-going medication review\cell GP\par Specialist\par Community nurse\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\par Copy of GP Management Plan offered to patient?  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f1\fs20 <<Copy of GPMP offered to patient?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f1\fs20 <<Copy of GPMP offered to patient?>>}}}}\plain\f1\fs20\par\plain\f1\fs20\b\par Copy / relevant parts of the GP Management Plan supplied to other providers?  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c00310039007c005900650073007c004e006f007c004e006f0074002000520065007100750069007200650064000000}{\*\txfieldtext \plain\f1\fs20 <<Copy of GPMP supplied to other providers?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||19|Yes|No|Not Required"}}{\fldrslt{\plain\f1\fs20 <<Copy of GPMP supplied to other providers?>>}}}}\plain\f1\fs20\par\par\plain\f1\fs20\b GP Management Plan added to the patient\loch\f1\hich\f1 \'92s records?  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f1\fs20 <<GPMP added to patient's records?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f1\fs20 <<GPMP added to patient's records?>>}}}}\plain\f1\fs20\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b Date service was completed:  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0044007c007c007c00310030007c00200020002f00200020002f0020002000200020000000}{\*\txfieldtext \plain\f1\fs20 <<Date service completed>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|D|||10|  /  /    "}}{\fldrslt{\plain\f1\fs20 <<Date service completed>>}}}}\plain\f1\fs20\cell\plain\f1\fs20\b Proposed Review Date:\plain\f1\fs24   {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0044007c007c007c00310030007c00200020002f00200020002f0020002000200020000000}{\*\txfieldtext \plain\f1\fs20 <<Proposed review date (recommended 6 months)>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|D|||10|  /  /    "}}{\fldrslt{\plain\f1\fs20 <<Proposed review date (recommended 6 months)>>}}}}\plain\f1\fs20\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9638\pard\widctlpar\intbl\pard\intbl\box\brdrs\brdrw5\brsp80\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\par I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan.  {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f1\fs20 <<Steps and costs explained, patient agreed>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f1\fs20 <<Steps and costs explained, patient agreed>>}}}}\plain\f1\fs20\par\plain\f1\fs20\b\par  \plain\f1\fs20 GP\loch\f1\hich\f1 \'92s Signature:  ________________________________________________\tab Date:___________________\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }