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Interactive PDSA workbookPilot version
Aboriginal and Torres Strait Islander health assessments
Fill this in as your practice works through a Plan-Do-Study-Act cycle on identification, health assessment uptake and follow-through. A completed cycle also meets the annual culturally safe practice requirement. Your answers save automatically on this computer. Come back across the data extractions and pick up where you left off. Written so the practice manager can drive it.
AuthorDr Chris Mitchell AM, FAICD
CPD hoursUp to 9 (EA 3 + RP 3 + MO 3)
TimelineThree data extractions, 3 to 6 months
Last savednot yet
Before you start: how this workbook saves
Type into the dashed magenta boxes. Each one shows an example answer above it. If you are not sure what to write, say the same kind of thing about your own practice.
Your answers save by themselves as you type, on this computer, in this browser. Close the tab, come back next week, everything will still be here. Check the 'Last saved' date on the cover.
Use one computer for the whole cycle, usually the practice manager's. If someone else needs to add their part, click Save to file, email them the file, and they click Load from file on their computer. Then they save to file and send it back.
Click Save to file at the end of every session. It downloads a small file. Keep it in your practice records folder. It is your backup if this computer is cleaned, replaced or reset.
When the cycle is finished, click Print / Save as PDF and choose 'Save as PDF'. That PDF is what the GPs upload as evidence to the RACGP CPD portal, and what you keep for accreditation.
One caution: clearing the browser's history or cache can delete your saved answers. The Save to file backup protects you.
This workbook is a pilot. If something is confusing or does not work on your computer, tell us via the contact page so we can fix it.
Your progress
0%
0 of 0 fields completed. This is a long activity. Do a section, close the tab, come back next week.
The four stages
PlanPick the problem. Decide what you will count and who does what.
DoRun the change. Hold the meetings. Record the numbers as you go.
StudyCompare the numbers across the weeks. Write down what you noticed.
ActKeep what worked. Drop what did not. Make the good changes permanent.
The shaded boxes show you what to write
Every question carries the answer from Dr Chris Mitchell's own cycle, run in a mixed rural practice working systematically through 33 regularly attending patients. You do not need to invent anything: read the example, then write the same kind of answer about your practice. The dashed magenta boxes are yours.
The learning: where your educational hours come from
Three of the nine hours are educational activities (EA). Your team earns them by reading and discussing the MBS, incentive and vaccination material, then applying it during the cycle. This also meets the annual culturally safe practice requirement. Chris wants this background on hand in every practice that runs the cycle.
The full background sits in the guide: patient identification and data extraction, health assessments and MBS billing, PIP Indigenous Health Incentive and CTG PBS Co-payment, vaccination schedules and care plans, and cultural awareness training requirements. Read it as a team at a practice meeting and log the time as EA.
MBS Online (mbsonline.gov.au) for current item 715, 228, 10987, 965 and 967 descriptors
Services Australia: PIP Indigenous Health Incentive and CTG PBS Co-payment registration through HPOS and PRODA
National Immunisation Program schedule for Aboriginal and Torres Strait Islander people
RACGP: culturally safe practice and the National guide to preventive healthcare
Your data extraction tool (Cubiko, PenCS or Doctors Control Panel)
Your PHN, for Aboriginal and Torres Strait Islander health support
For the practice manager
Email the guide page to every GP and nurse before the education meeting, so the reading is done by the time everyone sits down. The hours they spend reading and discussing it count toward EA, and this workbook records the rest.
Plan
Topic, idea and plan
Example
Identifying Aboriginal and Torres Strait Islander patients with unmet health needs, and improving health assessment uptake and follow-through.
Example
Most of the gap in preventive care for our Aboriginal and Torres Strait Islander patients is not about intent, it is about systems: identification at reception, recall and reminder processes, health assessment templates and MBS billing that do not flag eligible patients consistently. We wanted to identify these patients systematically, then work through assessment, incentive registration and follow-up.
Example
Map the current state: how many patients identify as Aboriginal or Torres Strait Islander, what proportion have had a recent health assessment (item 715), how many are registered for CTG PBS Co-payment and PIP Indigenous Health Incentive, and where the gaps sit in vaccination schedules and care plans. We ran the numbers in Cubiko and found 147 patients flagged, then cross-referenced against a Best Practice direct search, which returned 33 regularly attending patients. The discrepancy was inactive and non-attending patients in the broader extraction. We focused on the 33 active patients and worked through their care systematically, with three data extractions.
Example
All new patients are asked about their cultural status at registration. Active Aboriginal and Torres Strait Islander patients are offered a health assessment (item 715). Eligible patients are registered for CTG PBS Co-payment and PIP Indigenous Health Incentive. Cultural awareness training is met (at least two staff, including one GP). Vaccination schedules are reviewed against the NIP recommendations, and chronic condition management plans (item 965) are in place for eligible patients.
Do
Meeting and action schedule
Chris's practice ran three data extractions with planning, education and strategy meetings around them. Type your dates in as each one happens. These dates become part of the CPD evidence, so keep them accurate.
Milestone
Date
Executive planning meeting
Clinical discussion and education meeting
First data extraction
Strategy confirmation meeting
Second data extraction
Third data extraction
Follow-up meeting to confirm learnings
RACGP portal upload (GPs log their hours)
Study
Data collection
Run a data extraction at each of the three points and enter the totals here. Numbers only in the extraction boxes (33, not '33 patients'). The change column works itself out.
Example
The practice tracked the identified patients across three extractions: active patients identified, health assessments completed, CTG PBS and PIP Indigenous Health Incentive registrations, and chronic condition management plans in place. Working through the 33 regularly attending patients, assessment and registration numbers rose across the cycle as the recalls and updated template took effect.
What you are counting
Extraction 1
Extraction 2
Extraction 3
Change
What we learned
Example
The health assessment template was not titled as an Aboriginal and Torres Strait Islander health assessment, so we adopted the updated version as the preferred document. From 1 March 2026, items 715 and 228 no longer require age-based clinical activities: the assessment is holistic, so we updated our templates and workflows. Annual recalls were set for the Indigenous Health Incentive and the health assessment, and shortcuts were created for common documentation. Vaccination requirements were more complex than expected, particularly the pneumococcal sequence (Prevenar from age 50) and Shingrix eligibility from age 50, so the team needed education on the NIP schedule.
Act
What to keep and make permanent
Example
Cultural status is asked at registration for every new patient. The updated Aboriginal and Torres Strait Islander health assessment template is the standard document, matched to the holistic assessment rules that apply from 1 March 2026. Annual recalls run for the health assessment and the Indigenous Health Incentive. Documentation shortcuts are in place, and the team has had education on the NIP vaccination schedule for Aboriginal and Torres Strait Islander patients.
CPD hours
Count the hours each GP spent. Reviewing the MBS, incentive and vaccination material counts as EA, and also meets the annual culturally safe practice requirement. The data extraction and gap analysis count as RP. Running the cycle itself counts as MO. The total adds up automatically. When in doubt, the GP lead decides what to claim.
Activity type
Hours
Evidence you already have
Educational activities (EA)
Practice meeting attendance, the MBS and vaccination education session
Reviewing performance (RP)
The three data extractions and your gap analysis
Measuring outcomes (MO)
This completed workbook, the extraction numbers, meeting dates
Total
0
GPs submit as a GP-led activity via RACGP myCPD Home
This cycle also meets your culturally safe practice requirement
All three CPD homes require at least one activity a year addressing culturally safe practice. A completed cycle on this topic is direct evidence for that requirement, alongside the EA, RP and MO hours. Log the education time while you are there, because it is the part practices most often forget to claim.
Reflections (the GPs write these)
The RACGP asks each GP to reflect on three areas. Hand the computer to the GP lead for this bit, or collect a sentence or two from each GP at the follow-up meeting and type them in. There is no worked example here: these have to be your own.
Participating doctors
One per line. This is for your records so nobody has to reconstruct it at portal-upload time.