How do you draft a GP chronic condition management plan (GPCCMP) with an AI scribe?
The short answer: get the patient's consent to the scribe, then run the planning consult as you normally would. Use a template whose headings match what the MBS requires a GP chronic condition management plan (GPCCMP) to describe, and say the key elements out loud so the scribe can capture them. Before you offer the patient a copy and add it to their record, check the draft against the requirements. The scribe writes the first draft. The plan, and the claim, are still yours.
This is for Australian GPs. We build Hanah for GPs, so read it with that in mind. The MBS rules are linked to their official sources and are worth reading in full.
What changed on 1 July 2025?
From 1 July 2025, GP management plans (GPMPs) and team care arrangements (TCAs) were replaced by a single plan, the GPCCMP. According to the MBS factsheet on GPCCMP items:
- The items. A GP prepares a plan with item 965 (face to face) or 92029 (video), and reviews it with 967 or 92030. Prescribed medical practitioners use 392, 92060, 393 and 92061.
- No more collaboration step. You no longer need to consult two other providers. You refer directly, and allied health referrals are now letters rather than the old form.
- Where the patient gets it. Patients registered with MyMedicare must get GPCCMP services through the practice they're registered with. Other patients get them through their usual GP.
- How often. A plan can be prepared every 12 months and reviewed every 3 months, if it's clinically relevant to do so. Plans don't expire, but a patient needs a plan prepared or reviewed in the previous 18 months to keep accessing allied health services under it.
- Not on the same day as a consult. GPCCMP items can't be co-claimed with general attendance items on the same day.
Patients with a GPMP or TCA made before 1 July 2025 can keep using services under it until 30 June 2027 (transition factsheet). Services Australia keeps the current billing rules.
What does the written plan have to include?
The factsheet defines preparing a GPCCMP as writing a plan that describes:
- the patient's chronic condition or conditions and the health care needs that come with them
- health and lifestyle goals, developed with the patient through shared decision-making
- the actions the patient will take
- the treatment and services the patient is likely to need
- if multidisciplinary care would help, the services you'll refer them to and the purpose of each
- how and when the plan will be reviewed.
The process also has to include recording the patient's consent and agreement to the plan, offering a copy to the patient (and their carer, where appropriate and the patient agrees), and adding a copy to their medical record. If you're referring to members of a multidisciplinary team, you need the patient's consent to share the relevant parts of the plan with them.
Where does an AI scribe help, and where doesn't it?
A scribe is good at capturing what was said: goals in the patient's own words, the actions they agreed to, the services you discussed, the review timeframe you named. That's most of the writing in a plan.
It can't tell whether the patient is eligible, whether they're registered with MyMedicare at your practice, or whether a plan is clinically relevant now. It won't know the HbA1c result on your screen unless someone says it aloud. The RACGP advises against relying on an AI scribe to decide whether MBS requirements have been met. Hanah doesn't suggest item numbers at all.
How should you set up the template?
Make the headings match the MBS elements, so a missing element shows up as an empty section. Here is a structure you can use with any tool:
## Chronic conditions and health care needs
One line per condition, with the needs discussed for each.
## Goals
Health and lifestyle goals agreed with the patient, in their words where possible.
## What the patient will do
Actions the patient agreed to take, one per line.
## Treatment and services
Treatments and services the patient is likely to need.
## Referrals
Each service the patient is being referred to, and its purpose. Leave out if none.
## Consent
The patient's agreement to the plan, and whether they consent to relevant
parts being shared with the providers above. Record only what was said.
## Review
When and how the plan will be reviewed.
In Hanah you'd set this up with each heading as fixed text, reproduced as you wrote it, and a fill-in slot under it that carries the instruction. If something wasn't discussed, Hanah leaves the slot out rather than guessing. An empty Consent or Review section is your cue to fix it before you finalise. A GP's starting library includes a care plan template with goals, objectives, interventions and review headings. It's a reasonable start, but it doesn't match the GPCCMP elements one for one, so we'd rework it along the lines above.
What should you say during the planning consult?
The scribe can only draft what it hears. Near the end of the consult, a spoken recap does most of the work.
An illustrative example (the patient is fictional). Maria, 58, has type 2 diabetes and hypertension. Her GP closes the planning consult like this:
"So, to recap. You'd like to get your HbA1c down to 53 or under, and walk to the shops and back without stopping. You'll walk twenty minutes most days and check your feet every evening. I'm referring you to a dietitian to work through meals, and to a podiatrist for a foot assessment. Are you happy for me to send them the relevant parts of this plan? Good. We'll review it in three months."
That recap gives the draft its goals, patient actions, referrals, consent and review. The conditions section comes from the rest of the consult. Had the GP forgotten to ask about sharing, the Consent section would come back without it, which is easy to spot.
What should you check before you finalise it?
Read the draft against the requirements, not only for typos.
| Check | What to look for |
|---|---|
| Conditions and needs | Every condition the plan covers is named, with its needs |
| Goals | The patient's goals, agreed with them rather than assigned to them |
| Patient actions | Specific things the patient will do |
| Treatment and services | What they're likely to need, including services outside the MBS |
| Referrals | Each service with its purpose |
| Consent | Agreement to the plan, and consent to share with the team |
| Review | A proposed timeframe |
| Accuracy | Medicine names, doses and laterality, and past history kept separate from current problems |
The last row comes from the RACGP's list of common scribe errors: mishearing medicine or condition names, and confusing historical symptoms with current ones.
How do referrals under the plan work?
Referrals to allied health services are now letters. The MBS referral factsheet sets the minimum. A referral must be written, signed (electronically is fine) and dated. It must include your name and your practice address or provider number, and explain why you're referring, with the information about the patient's condition the provider needs. Allied health referrals under the plan are valid for 18 months from the first service unless you say otherwise. They don't need to name a provider or set a number of services.
In Hanah, a referral letter is a template like any other. Today's date, your name, the practice name and the patient's name are filled in automatically. Type your provider number and practice address into the template as fixed text and they'll appear on every letter. The signature is yours to add.
How does a GPCCMP review work?
A review (967 or 92030) means discussing and documenting progress against the plan's goals and whether the plan needs updating, taking into account whether the goals are still right and what the rest of the team has reported. The review arrangements are updated, the patient agrees to the changes, they're offered a copy, and a copy goes in their record.
Hanah helps in two ways. When you draft the same template for the same patient again, it uses the most recent earlier version as a guide to structure and to what was tracked last time. The clinical facts in the new draft still come only from the review consult. And if the plan was discussed across more than one recorded visit, a document can draw on several visits at once.
How does the patient get their copy?
You can email the finished plan to the patient from Hanah, to the address on file or one you type in. Hanah doesn't connect to Best Practice, MedicalDirector or My Health Record. The copy in the patient's medical record is one you paste into your clinical system, and the formatting comes across with it.
Separately, Hanah can keep a care plan written for the patient. It lives in their app and uses plain language, with jargon explained where it appears. It's a companion to the GPCCMP, not a replacement for the copy the MBS requires you to offer.
FAQ
Can a practice nurse help prepare the plan? Yes. The factsheet says a practice nurse, Aboriginal and Torres Strait Islander Health Practitioner or Aboriginal Health Worker may help prepare or review a GPCCMP. The GP or prescribed medical practitioner claims the item.
Do I need the patient's consent for the scribe as well as for the plan? Yes, they're separate. The RACGP says to get consent to the AI scribe at the start of each consultation, and the MBS requires you to record consent to the plan itself.
Is there a mandated GPCCMP template? The factsheet lists what the plan must describe but doesn't set out a required form. The layout is up to you, as long as it covers every element.
To see how Hanah drafts plans, referrals and notes from the consult, see Hanah for GPs or book a demo below.