Table 2 Consultation action data items collected when applicable

Observations

Blood pressure, heart rate, height, weight, BMI, temperature, oxygen saturation, respiratory rate

Examinations

System(s) examined whether in full or in part and linked to which problem(s)

Medications prescribed

Any medication prescribed, given during the consultation, or recommended to be obtained and taken by the patient. Up to 8 can be listed. The following 4 items are collected for each medication

   Drug name

Identification of the medication

   Administration route

How the medication is taken or applied to the patient

   Drug status

New/Continued. “New” if the patient was not taking this medication before the consultation

   Linked to problem

List the problem number(s) this medication related to

Medications reduced with the intention to cease later

Any medication that is intended to be deprescribed but requires weaning to be able to cease safely. Up to 8 can be listed. The following 5 items are collected for each medication

   Drug name

Identification of the medication

   Administration route

How the medication is taken or applied to the patient

   Prescription duration in months

Indicate if the patient has been taking the medication for less than 3 months or for 3 months or more

   Reason(s) to reduce medication

List one or more reasons

   Linked to problem

List the problem number(s) this medication related to

Medications ceased

Any medication that is deprescribed. Up to 8 can be listed. The following 5 items are collected for each medication

   Drug name

Identification of the medication

   Administration route

How the medication is taken or applied to the patient

   Prescription duration in months

Indicate if the patient has been taking the medication for less than 3 months or for 3 months or more

   Reason(s) to cease medication

List one or more reasons

   Linked to problem

List the problem number(s) this medication related to

Pathology

List up to 12 tests requested and indicate which problems/diagnoses each one related to

Referred imaging / other tests

List the name of the imaging or other test, the body site it related to and indicate which problems/diagnoses each one related to

Procedures

List the procedures undertaken in the consultation and indicate which problems/diagnoses each one related to

Referral

Record any referrals to a government funded clinic/specialist, private specialist, private allied health, other agency, emergency department or hospital. Record the specific type of service and indicate which problems/diagnoses each one related to

Follow-up arranged

When specific follow-up arrangements are made, record if it is an appointment with the participant, another GP at the same practice, the practice nurse, or via telephone

Antibiotic prescribing

When an antibiotic was prescribed indicate if it was for immediate use or was a delayed prescription