Documenting a GP clinic day
Consultation notes, chronic condition plan reviews, referral letters and work certificates.
A chronic condition management plan review
Plan review. Type 2 diabetes and stage 3a CKD.
HbA1c 8.1, up from 7.4. eGFR 52, urine ACR 12. BP 142/86, weight 98 kilos.
Metformin 1 g BD continues. Add empagliflozin 10 daily for glucose and kidney protection. Sick day advice given.
Perindopril up from 5 to 10. EUC in two weeks.
Referrals to the dietitian and the podiatrist under the plan. Review in three months with a repeat HbA1c.
Reason
Chronic condition management plan review. T2DM, CKD stage 3a.
Results
HbA1c 8.1% (7.4%). eGFR 52. uACR 12 mg/mmol. BP 142/86. Weight 98 kg.
Changes
- Empagliflozin 10 mg daily (new); sick day advice given
- Perindopril increased 5 to 10 mg
- Metformin 1 g BD unchanged
Plan
- EUC in 2 weeks
- Dietitian and podiatry referrals
- Review in 3 months with HbA1c
Out of the consultation
- Referral letters
- To allied health under the plan, and to a specialist with the clinical question first.
- Urgent referral
- With the timeframe stated and what has been started in the meantime.
- Work certificate
- Drafted from the same consultation when one is needed.
