Creating a comprehensive Care Plan Review requires precision and attention to detail, especially for general practitioners who manage diverse patient needs. Here’s a detailed walkthrough of how to correctly format and document a Care Plan Review using a structured template.

1. Review of Care Plan

Begin with a clear review of the existing care plan. Indicate the date of the original plan and acknowledge any updates. For example:

Review of Care Plan: Care plan initially created by the facility on 01/15/2023. Diagnoses have been reviewed and updated accordingly.

2. Past Medical History

Detail the patient's medical history, including active and inactive conditions, relevant tests, and advance health directives. For example:

Past Medical History: Date of medical history: 01/10/2023. Active conditions include Hypertension (diagnosed 03/2018) and Type 2 Diabetes (diagnosed 06/2020). Inactive condition: Asthma (resolved 05/2015). Relevant tests: HbA1c 7.2% (01/05/2023), Blood Pressure 130/85 mmHg (01/10/2023). Advance directive status: Living will dated 02/20/2020.

3. Medications

List all current medications, including dosages, and confirm the patient's medication list is current. For example:

Medications: Current medications include Metformin 500mg twice daily and Lisinopril 10mg once daily. Patient's PMC has been checked for updated medication listings.

4. Immunisation

Provide details of the patient's immunisation status. For example:

Immunisation: Influenza vaccine administered in 10/2022; COVID-19 booster received in 11/2022.

5. Allergies

Clearly state any known allergies. For example:

Allergies: Penicillin.

6. Psychosocial History and Functional Assessment

Include information on the patient's psychosocial history, care providers, and functional assessments. For example:

Psychosocial History and Functional Assessment: Advance care directive is active. COVID vaccine status is up to date. Care providers include Dr. Sarah Lee (Endocrinologist) and Dr. John Smith (Cardiologist). Last GP visit was on 01/10/2023.

7. Significant Events

Summarize any significant events since the last review. For example:

Significant Events: Hospital admission for chest pain on 12/15/2022. Medication adjustments were made on 01/05/2023.

8. Recommendations / Actions

Provide actionable recommendations and instructions for the patient’s ongoing care. For example:

Recommendations / Actions: Increase physical activity to 30 minutes daily. Monitor weight changes weekly, with recent weight at 180 lbs on 01/10/2023. Maintain blood pressure within 120-140/80-90 mmHg. Monitor fasting glucose daily and assess pain using a pain scale at each visit. Monthly urinalysis for microalbumin is advised, with monitoring for hypoglycemia signs.

9. Signature and Date

Conclude with the reviewing doctor's signature and the date of the review. For example:

Signature of the reviewing doctor: Dr. Thomas Kelly. Date of review: 01/15/2023.

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