Review a chronic disease management plan
You are an enrolled nurse in the general practice nursing team at Warners Bay.
What has happened
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.
Deliverables
- 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
Documents to use
Systems to use
Patient Records and Appointments
The appointment book and patient register for all sites, recording bookings, arrivals, clinicians, consultation type and follow-up actions.
Pathology Specimen Register
Records every specimen collected at Toronto and in the treatment rooms, with the tests requested, collector, storage, courier despatch and laboratory outcome.
Pharmacy Stock, Imprest and Cold Chain
Manages pharmaceutical stock levels, imprest supply to the treatment rooms and dental clinic, expiry tracking, scheduled medicine control and fridge monitoring.
Units of competency
Current on training.gov.au for the Health as at 10 September 2026.
HLTENN037Perform clinical assessment and contribute to planning nursing careHLTENN038Implement, monitor and evaluate nursing careHLTENN044Implement and monitor care for a person with chronic health conditionsHLTENN047Apply nursing practice in the primary health care settingHLTAAP002Confirm physical health statusHLTENN045Implement and monitor care of the older personQualifications
HLT54121Diploma of NursingWhat to look for
Evidence guide
The assessment must be structured, complete and recorded in a form another clinician can use. The stopped medicine must be escalated, not managed by the nurse, and the escalation documented with the response. Goals must be in the patient's words and measurable. Referrals must show consent to share. Look for the student recognising the falls, foot and nutrition risks and coordinating rather than duplicating the general practitioner's role.