The Annual Cycle of Care document will sit in the Care Plan tab of any eligible Inca patient. The PDF document will auto-populate as the relevant tasks in the care plan are completed or appointments are marked as attended. 

All tasks must be completed and appointments attended within the last 12 months. Where the frequency is twice per cycle, dates must be a minimum of 4 months apart. It must not be approved within 3 months of a 732. 

Measure eGFR - Once per cycle 

Care plan task: Serum creatinine test (Biomedical --> Monitor renal function) 

Serum Creatine test results must be stored in the Measurements tab of the patient's Inca record. These can be uploaded from the practice software record or manually entered. The SC value will generate the eGFR value. The 'date of entry' will be displayed in the care plan tab and will automatically mark the task as complete

Measure weight and height and calculate BMI - Twice per cycle 

No linked care plan task 

Measurements for height and weight must be taken on two separate occasions and stored in the Measurements tab of the patient's Inca record. These measurements can be uploaded from the practice software record or manually entered

Measure Blood Pressure - Twice per cycle 

Care plan task - Measure blood pressure (Biomedical --> Control blood pressure) 

Blood pressure must be taken on two separate occasions and stored in the Measurements tab of the patient's Inca record. These measurements can be uploaded from the practice software record or manually. The 'date of entry' will be displayed in the care plan tab and will automatically mark the task as complete

Examine feet - Twice per cycle 

Care plan task - Foot examination (Complications --> Avoid foot complications) 

Two attended appointments must be added to the care plan task Foot examination

Assess diabetes control by measuring HbA1c - Once per cycle of care 

Care plan task - HbA1c test (Biomedical --> Control blood glucose) 

HbA1c test results must be stored in the Measurements tab of the patient's Inca record. These can be uploaded from the practice software record or manually entered. The 'date of entry' will be displayed in the care plan tab and will automatically mark the task as complete

Measure total cholesterol, triglycerides and HDL cholesterol - Once per cycle 

Care plan task - Lipids test (Biomedical --> Control lipids) 

HDL, LDL, Total Cholesterol and Triglycerides test results must be stored in the Measurements tab of the patient's Inca record. These can be uploaded from the practice software record or manually entered. The 'date of entry' will be displayed in the care plan tab and will automatically mark the task as complete

Test for Microalbuminuria - Once per cycle 

Care plan task - Microalbuminuria test (Biomedical --> Monitor renal function) 

Microalbumin test results must be stored in the Measurements tab of the patient's Inca record. These can be uploaded from the practice software record or manually entered. The 'date of entry' will be displayed in the care plan tab and will automatically mark the task as complete

Ensure that a comprehensive eye examination is carried out - Every 2 years

Care plan task - Comprehensive eye examination (Complications --> Minimise eye problems) 

An attended appointment must be added to the care plan task Comprehensive eye examination. This task must be assigned to an Optometrist

Provide self-care education - Once per cycle 

Care plan task - Education and review (General --> Clear understanding on conditions)

An attended appointment must be added to the care plan task Education and review

Review diet - Once per cycle 

Care plan task - Education and review (Lifestyle --> Maintain healthy diet) 

An attended appointment must be added to the care plan task Education and review

Review levels of physical activity - Once per cycle 

Care plan task - Education and review (Lifestyle --> Maintain physical activity) 

An attended appointment must be added to the care plan task Education and review

Review of medication - Once per cycle 

Care plan task - Medication review (Medications --> Correct use of medications) 

An attended appointment must be added to the care plan task Education and review

Check smoking status - Once per cycle

No linked care plan task 

Smoking status must be entered in the Health Summary tab of the patient's Inca record