Care Planning

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (ME/CFS) management in Australian Primary Care Settings is based around the Medicare Chronic Disease Management items. These include an Annual Care Plan, Team Care Arrangements, an Annual Review of health outcomes, Health Coaching/Education and referrals to Allied Health Providers.

The following resources are provided to assist you, to support your patients and provide care in the time limits of General Practice Consultations.

1. ME/CFS Nurses Management, Care Plan Resources/Workshops: please contact bpclients5159@gmail.com

1. ME/CFS Nurses Handbook
2. GP Management Plan Template with Supplementary Questions
3. Annual ME/CFS Management Cycle of Care 12-month Record Template – Helps patients with managing records and documentation
4. Pre-appointment phone assessment form – use practice in-house form
5. Medicare Care Plan Appointment Checklist
6. ME/CFS Patient Handbook

 2.  ME/CFS Diagnostic Assessment and Review Tools download Assessment Tools here

1. IACFSME Primer 2014: ME/CFS Clinical Criteria Worksheet
2. IACFSME Primer 2014: Pediatric ME/CFS Case Definition Worksheet
3. ME/CFS Canadian Multisystem Questionnaire
4. South Australian Tool to Separate ME/CFS and Depression

3. Additional Assessment and Monitoring Tools

• NASA 10 Minute Lean Test
• Australian modified Karnofsky Performance Scale (AKPS)
• Bell’s Functionality Score (Disability Scale Assessment)
• Epworth Sleepiness Scale
• DASS 21 (Depression, Anxiety & Stress Scale)

4. Useful Clinical Forms for patients to complete before Consultations: please contact bpclients5159@gmail.com for workshop timetable

1. ME/CFS Registration Form – Diagnostic
2. Patient Pre-Appointment Health Care Check List
3. Patient Pre-Appointment Notes for Care Plan
4. Patient Pre-Appointment Action Plan Goals
5. Annual ME/CFS Management Cycle of Care 12-month Record Template – Helps patients with managing records and documentation

5. Patient Information Sheets – Introductory Series on ME/CFS Management & Care Planning download Patient Handouts here

6. Additional information and resources download References here

• International ME/CFS GP Primer, 2014
• Diagnosing and Treatment ME/CFS V2, U.S. ME/CFS Clinician Coalition, 2020
• ME/CFS Diagnosis and Management in Young People, 2017
• ME/CFS International Consensus Criteria, 2011
• Other Core Documents
• Bateman Horne Center 
• US ME/CFS Clinician Coalition
  • Clinical Management
  • Medical Education
  • Resources

 For more information contact bpclients5159@gmail.com

The South Australian ME/CFS, FMS Clinic Research Collaboration is working to continually provide current best practice services and programs available across Australia.
We welcome your suggestions and input: email bpclients5159@gmail.com.