Review a chronic disease management plan

What is going on

Margaret Ellwood (LH-10482), aged 74, lives alone and has type 2 diabetes, hypertension and early chronic kidney disease. She attends on Monday for the annual review of her chronic disease management plan and team care arrangement. Her glycated haemoglobin, kidney function and urine albumin results from Thursday's pathology collection are in the record. She reports that she has stopped one of her blood pressure tablets because it made her dizzy, that her feet feel numb at night and that she is finding it hard to cook for one. The Medical Director will review and sign the plan and has asked to be told before Margaret leaves if her blood pressure readings are a concern.

Your brief

Complete the nursing assessment within your scope, review the pathology results and the medication changes, agree goals with Margaret, coordinate the podiatry and dietetics referrals, document the assessment and the draft plan in the patient record and escalate the medication and blood pressure issues to the Medical Director.

Work through it

You do not need to do it all. Doing a few of these will show you what the work is like. Your ticks and notes stay on this device.

• Read the Medication Management and Scheduled Medicines Policy and the Privacy and Health Records Policy and note what you can and cannot do with the stopped medicine and with sharing information with allied health.
• Open Margaret's record in the Patient Records and Appointments system and review the appointment, the follow-up notes and the pathology entries linked to specimen SP-26-40920.
• Complete a structured nursing assessment: vital signs, weight, blood glucose, foot check, falls risk, nutrition and social supports, and record it in the patient record.
• Record the stopped antihypertensive and the reported dizziness as a medication issue and escalate it to the Medical Director before Margaret leaves, documenting the escalation and the response.
• Agree three goals with Margaret in her own words and draft the updated plan and team care arrangement with the general practitioner, podiatrist and dietitian as the team.
• Prepare the podiatry referral for the numb feet and the dietetics referral for cooking and nutrition using the Allied Health Treatment Plan and Delegation Template as the referral summary, with consent to share recorded.
• Update the follow-up field in the patient record with the recall dates for the next review, the results follow-up and the referrals, and mark the appointment completed.
• Write a handover note for the Medical Director summarising the assessment, the escalations and the draft plan ready for review and signature.

What someone in this role would produce

• Documented nursing assessment in the patient record
• Draft chronic disease management plan and team care arrangement
• Two referral summaries with consent recorded
• Escalation record for the medication issue
• Handover note to the Medical Director