GP MANAGEMENT PLAN - MBS ITEM No. 721
CHRONIC LIVER DISEASE

Patient’s Name: <PtName> | Date of Birth: <PtDoB>

Contact Details: | Medicare or Private Health Insurance Details:

<PtAddress>

<PtMCNo>
<PtHealthIns>

Details of Patient’s Usual GP: | Details of Patient’s Carer (if applicable):

<DrName>
<DrAddress>

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

<PMHAll>

FAMILY HISTORY particularly haemochromatosis and hepatocellular carcinoma 

<FamilyHx>

MEDICATIONS 

<CurrentRx>

ALLERGIES

<Reactions>

SMOKING STATUS

<SmkStatus>

ALCOHOL INTAKE

<AlcHx>

Patient’s Name: <PtName>

GP MANAGEMENT PLAN - MBS ITEM No. 721
CHRONIC LIVER DISEASE

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 | | |

Patient's understanding of their condition

Patient to have a clear understanding of their condition and patient's role in management.

Patient education/support
Patient resources

GP / nurse 
Educator / support group

2. Lifestyle | | |

Nutrition

Maintain healthy diet

Patient education

Patient to implement
GP to monitor 
Dietitian

Weight

Your target: BMI <   
Ideal: BMI ≤ 25 kg/m^2

Monitor
Review 6 monthly

Patient to monitor
GP to review

Physical activity

Your target:

Ideal:
Exercise at least 30 minutes walking or equivalent 5 or more days per week

Patient exercise routine

OR 
As per Lifescripts action plan

Patient to implement
GP to review
Exercise physiologist

Smoking

Complete cessation

Smoking cessation strategy:
Consider:
- Quit
- Medication

Patient to manage
GP to monitor and support
Refer to ATODs

Alcohol intake

Your target: Complete cessation or if unable < 2  standard drinks per day

Reduce alcohol intake
Patient education

Patient to manage
GP to monitor and support
Refer to ATODs

Other drugs

Abstinence or safe use

Counselling
Medication including OST if appropriate

Patient to manage
GP to monitor and support
Refer to ATODs

Co-morbidities

New infections HIV, HCV, HBV
New clinical problems

Re-testing for infection, general examination based on history

Pathology referral

3. Biomedical | | |

Liver function tests:
ELFTs, FBC, coagulation studies
Where appropriate, Vit D, alpha-foetoprotein

Monitor for early detection of complications or deterioration in liver function, determination of level of risk

Check every 6-12 months

GP
Refer to specialist if significant deterioration

Liver ultrasound
APRI - score
+/- FibroScan

Monitor for development of cirrhosis, portal hypertension, varices and hepatocellular carcinoma

Check every 6-12 months

GP
Refer to specialist if required

4. Medication | | |

Medication review

Correct use of medications, minimise side effects especially hepatotoxicity

Patient education
Review medications

GP to review and provide education
Pharmacist

5. Other | | |

Vaccination

Prevent infection with Hepatitis A/B
Prevent influenza- or pneumococcal infection related complications

Immunise against Hep A/B
Annual influenza immunisation
One-off pneumococcal vaccination or two five years apart for ATSI patients

GP
Nurse

Mental health

Monitor for depression/anxiety in the context of chronic disease

Psychoeducation
Referral to a psychologist if required
Anti-depressant medication

GP
Psychologist

Bone density
Vit D levels

Detect and manage osteoporosis to prevent fractures

BMD every 2-3 years
Prescribe bisphosphonates or other medication as appropriate

GP

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:  __________________________________________	Date:___________________

Reviewed February 2020
Original template compiled by Monash Division of General Practice, March 2006