Asthma care planning in Australian general practice can involve two documents with different purposes: a patient-facing Written Asthma Action Plan and a GP chronic condition management plan (GPCCMP). GPs need to choose the right template, apply age- and regimen-specific guidance, and keep each document current. Here is a practical way to prepare both without blurring their clinical care and Medicare Benefits Schedule (MBS) purposes.

Asthma Action Plans and GPCCMPs serve different purposes

A Written Asthma Action Plan gives a patient or carer personalised instructions for everyday treatment, worsening asthma and an emergency. The Australian Asthma Handbook recommends an individualised plan for every adult or adolescent with asthma and separate age-appropriate plans for children.

A GP chronic condition management plan (GPCCMP) is a broader shared-care document. It records the patient's chronic conditions and health needs, agreed goals and actions, likely treatment and services, any useful multidisciplinary referrals, and review arrangements.

Many patients may benefit from both. A GPCCMP can refer to or include a copy of the current Written Asthma Action Plan, but it does not replace the patient's stand-alone instructions for worsening asthma and emergencies.

Start with the Written Asthma Action Plan

The National Asthma Council plan library provides colour, black-and-white, fillable, editable and translated templates. It also includes regimen-specific options. Choose a template that fits the patient's age, treatment, exacerbation risk, culture, preferred language, literacy and ability to self-manage.

What the plan should include

The Australian Asthma Handbook guidance calls for patient-specific instructions covering:

• Everyday care: usual asthma and allergy medicines, including the prescribed dose and frequency.
• Worsening asthma: the patient's signs of deterioration, medication adjustments and when to obtain medical review.
• Urgent and emergency care: danger signs, asthma first aid, when and how to seek urgent care, and when to call 000.
• Plan details: current medical and emergency contacts, the preparer's name and the date.

A traffic-light layout is common, although no single colour scheme or universal dose threshold suits every patient. The written instructions must match the prescribed regimen and the person's risks. Avoid copying generic doses or peak-flow cut-offs into a plan.

Match instructions to age and treatment

Version 3.0 of the Australian Asthma Handbook changed the adult and adolescent treatment context. For people aged 12 years and over, the current treatment guidance no longer recommends short-acting beta2 agonist (SABA)-only treatment. Treatment includes an inhaled corticosteroid (ICS), with options such as anti-inflammatory reliever (AIR)-only therapy, maintenance-and-reliever therapy (MART), or maintenance ICS-based treatment. The action plan must match the chosen regimen and the specific inhaler approved for that use.

Children need their own pathway:

• For children aged 6 to 11 years, salbutamol remains the first-choice reliever. Anti-inflammatory reliever therapy is not approved for this age group by the Therapeutic Goods Administration.
• A child's plan should cover worsening, substantial worsening and emergencies. The child action-plan guidance excludes parent-initiated oral corticosteroids.
• Children aged 1 to 5 years follow the Handbook's separate preschool asthma pathway.

Peak expiratory flow (PEF) is optional rather than a standard field for every plan. It may help some people with severe or difficult-to-control asthma, or limited awareness of airflow restriction. When used, instructions should be based on the person's personal best. PEF monitoring is not recommended for children under 12, for whom symptom-based plans are preferred. The National Asthma Council's action-plan overview explains these boundaries.

Review and share the current version

Review an adult or adolescent's Written Asthma Action Plan every year and whenever treatment or asthma status changes significantly. At a review, reassess symptoms and exacerbations, triggers, risk, lung function where indicated, inhaler technique, adherence, adverse effects and comorbidities, then update the plan.

Review a child's plan at least yearly and whenever control or medicines change significantly. Give the patient or carer a usable copy and retain the current version in the patient record. For children, share an up-to-date copy with the school, preschool or childcare service and relevant carers, subject to the service's local requirements.

An education and care service may also request its own care or risk-minimisation form. That form serves a setting-specific administrative purpose and does not replace the standard Asthma Action Plan used at home.

Use a GPCCMP for broader chronic care

Asthma can satisfy the chronic-duration criterion, but diagnosis alone does not create entitlement to a GPCCMP item. Under MBS Note AN.0.47, the patient must have at least one condition that has been, or is likely to be, present for at least six months, or is terminal. The GP or prescribed medical practitioner must also judge that the structured plan is clinically relevant and beneficial. GPCCMP items are unavailable to residents of residential aged care facilities.

A compliant written GPCCMP describes:

• the chronic condition and associated health needs
• health and lifestyle goals agreed through shared decision-making
• actions the patient will take
• likely treatment and services
• useful multidisciplinary referrals and the purpose of each service
• review arrangements and the proposed timeframe.

The practitioner must record the patient's consent and agreement, offer a copy to the patient and an appropriate carer where agreed, and add the plan to the patient record. When information will be shared with multidisciplinary providers, the practitioner must obtain and record consent and provide the relevant parts where the patient agrees.

For asthma, the GPCCMP can record goals such as improving symptom control, reducing exacerbation risk, checking inhaler technique or addressing modifiable triggers. Cross-reference the current Written Asthma Action Plan so the broader care record and the patient's instructions stay aligned.

Current MBS items and schedule fees

The MBS lists eight GPCCMP items. The schedule fees below were updated on 1 July 2026. They are schedule fees and listed benefits, not guaranteed rebates or out-of-pocket costs. Actual patient costs depend on the practice's billing arrangements.

The four telehealth items are for video attendances, not telephone consults. They use the same MyMedicare or usual-medical-practitioner requirements as face-to-face GPCCMP services and are unavailable for admitted hospital patients.

A plan can generally be prepared no more than once every 12 months, and a new plan must be at least three months after the last review. Reviews can generally be claimed no more than once every three months. An earlier service may be available after a significant change in the patient's clinical condition or care circumstances. Document the exceptional circumstances and flag the claim as required.

A GPCCMP does not expire. Preparation or review within the previous 18 months is required for continued access to relevant MBS-supported allied health and other services. The practitioner must attend the patient, discuss the plan, and be satisfied that the patient understands and agrees with it, even when another team member assists with preparation.

GP Management Plans and Team Care Arrangements prepared before 1 July 2025 can continue to support eligible services until 30 June 2027. Do not claim a new GPCCMP review item to review one of those old plans. When review is needed, prepare a GPCCMP if clinically appropriate. MBS Note AN.15.5 sets out the transition.

A practical workflow for the consult

1. Confirm the document needed. Prepare or update the Written Asthma Action Plan for self-management. Add a GPCCMP only when a broader structured plan is clinically useful and the MBS requirements are met.
2. Review current asthma care. Reassess control, exacerbations, risk, lung function where indicated, inhaler technique, adherence, medicines, adverse effects, comorbidities and triggers.
3. Choose an appropriate action-plan template. Match it to age, regimen, language, literacy and self-management ability.
4. Write patient-specific instructions. Confirm usual medicines, worsening steps, urgent care, emergency action, contacts, author and date.
5. Complete the GPCCMP separately. Agree on goals, patient actions, treatment, services, referrals and review arrangements. Record consent and agreement.
6. Reconcile both documents. Check that medicines, goals, contacts and review timing agree wherever they overlap.
7. Review with the patient. Confirm that the patient or carer can follow the action plan and understands the GPCCMP. Offer the required copies and share relevant information with consent.
8. Save and distribute the current versions. Keep both in the patient record and give the action plan to the people who may need to use it.

How Lyrebird supports GPCCMP documentation in Bp Premier

Clear separation between these documents helps patients receive usable emergency instructions while the broader chronic-care record remains complete. Our Bp Premier integration reads from and writes to Bp, and its current GPCCMP workflow supports items 965 and 967.

For this Bp Premier GPCCMP workflow, obtain and record the patient's consent for recording and documentation before starting capture. This workflow requirement does not imply a universal legal consent rule for all AI-scribe use.

Lyrebird can then use the consult and Bp history to prefill a draft GPCCMP. You review and edit the plan, confirm any past medical history entries, prepare referral letters where needed, and save the reviewed document to Correspondence Out. Bp Premier remains the patient record.

This workflow supports GPCCMP documentation. The patient-facing Written Asthma Action Plan should still be completed in an appropriate clinical template and shared separately. The GP remains responsible for clinical relevance, MBS eligibility, the required discussion and agreement, and final accuracy.

To see how this workflow fits your practice, contact us.