<<Miscellaneous:Practice Letterhead>>
Fax <<Practice:Fax>>
Tel <<Practice:Phone>>

GP MANAGEMENT PLAN - MBS ITEM No. 721 (Childhood Disability)	

Patient’s Name: 
<<Patient Demographics:Full Name>>	Date of Birth: 
<<Patient Demographics:DOB>>	

Contact Details:		Medicare or Private Health Insurance Details:	
<<Patient Demographics:Full Address>>	<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>	

Details of Patient’s Usual GP:	Details of Patient’s Carer (if applicable):	
<<Doctor:Name>>
<<Doctor:Full Address>>
Provider No: <<Doctor:Provider Number>>	Name: 
<<Name of of Patient’s Carer (if applicable):>>
Relationship to Patient: 
<<Relationship of Carer to Patient>>
Tel: 
<<Contact Telephone or Mobile No of Carer >>

Date of last Care Plan/GP Management Plan (if done):  
<<Date of last Care Plan/GPMP>>

Other notes or comments relevant to the patient’s Management Plan: 

	

PAST MEDICAL HISTORY

<<Clinical Details:History List>>

FAMILY HISTORY 

<<Clinical Details:Family History>>

SOCIAL HISTORY 

<<Clinical Details:Social History>>

MEDICATIONS 

<<Clinical Details:Medication List>>

ALLERGIES

<<Clinical Details:Allergies>>

Patient’s Name: <<Patient Demographics:Full Name>>

GP MANAGEMENT PLAN (Childhood Disability)	

Patient problems / needs / relevant conditions	Goals - changes to be achieved	Required treatments and services including patient actions	Arrangements for treatments/services (when, who, contact details)	
1. General				
Family and/ patients understanding of disability	Family and/patient to have a clear understanding of disability and their role in ongoing management	Family and patient education 	GP 
Paediatrician
Social worker
Occupational Therapist
Physiotherapist
Speech therapist	
2. Development				
Language development 	Enabling the child to acquire the capacity to communicate their wants or needs, feelings and thoughts with another
	Assist receptive language development, the ability to receive and understand language. To be able to understand the thoughts, feelings, desires and the needs of others
	GP to monitor
Allied Health Services
Speech Therapist	
Non verbal communication	Enabling the child to recognize and communicate through body language, gestures and facial expressions 	Play therapy / Early Intervention	Allied health professionals
	
Social skills	The child learns the skills, rules and values that will enable them to form connections and function among family members, peers and members of society	Assist expressive language development, the ability to speak and use language to communicate.
Family and patient education	GP
Family
Allied health professionals	
Cognitive development	To help develop the functions of the brain including perception, memory, imagination and use of language	Play therapy / Early Intervention 	GP
Family
Allied health professionals	
Emotional skills	The child is able to understand, express and regulate their emotions	Play therapy / Early Intervention	GP to monitor
Allied Health Services	
Gross motor skills
	To increase the abilities that requires coordination of large muscles of the body such as jumping or climbing	Patient exercise routine	Physiotherapist	
Fine motor skills
	To increase the abilities that require coordination of the small muscles of the body 	Play therapy / Early Intervention	Play therapist
Physiotherapist
Occupational Therapist	
Physical development
Growth	Achieve appropriate height, weight, muscle development and bone thickness	Normal healthy diet	GP
Family
Dietitian
Maternal and child health nurse	
Gait	The ability to move symmetrically, where both legs move at the same time	Exercise routine	Physiotherapist	
3. Daily Living Skills				
Ability to carry out activities of daily living	Enabling the child to carry out the necessary tasks and functions required to function on a daily or regular basis	Assisting the child to grow and develop and to obtain additional skills to become as independent as possible	GP
Family/child
Allied Health professionals	
4. Biomedical				
Investigations	Early detection and treatment of any problems	Pathology as required
Radiology as required	GP	
5. Medication				
Medication review	Correct use of medications, minimise side effects	Family and/ patient education
Review medications	GP to review and provide education	
6. Preventative care				
Childhood immunisations	Preventative care	Ensure up to date with all childhood immunisations	GP
Family	
Eye care	Early detection and treatment of any problems	Initial eye check and ongoing review and treatment as required
Referral by GP	GP
Eye specialist	
Foot care	Prevent foot complications	Patient education on foot care
Patient/ family to check feet regularly
Check feet every 6 months	GP / podiatrist 
Patient/family
GP	
7. Family support				
Family’s need for assistance support	Honest communication between patient, family, GP and health care professionals.
	Honest communication between patient, family, GP and health care professionals.
Case management
Carer respite
Disabled parking
Carer allowance / pension	GP
Patient 
Family
Health care professionals
Local Council
home help	

Copy of GP Management Plan offered to patient?  
<<Copy of GPMP offered to patient?>>

Copy / relevant parts of the GP Management Plan supplied to other providers?  
<<Copy of GPMP supplied to other providers?>>

GP Management Plan added to the patient’s records?  
<<GPMP added to patient's records?>>

Date service was completed:  
<<Date service completed>>	Proposed Review Date:  
<<Proposed review date (recommended 6 months)>>	

I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan.  <<Steps and costs explained, patient agreed>>

GP’s Signature:  x_______________________________________________

Date: <<Miscellaneous:Date>>

 GP Name:  <<Doctor:Name>>