Medicare Annual Wellness Visit (AWV) Note

Date: [Date of visit]

Patient: [Patient name] | DOB: [DOB] | MRN: [MRN]

Provider: [Provider name, credentials]

Clinic/Site: [Clinic or site name] [telehealth / in-person]

Visit Type: [Initial AWV / Subsequent AWV]

Eligibility: [Eligibility confirmed / Eligibility not fully verified] (Confirm patient is beyond 12 months of Part B enrollment and >12 months since any prior AWV or IPPE. If not confirmed, document what was checked and what remains unverified.)

Interpreter: [Language and modality] (Only include if interpreter used.)

Caregiver/Family Present: [Name and relationship] (Only include if applicable.)

Health Risk Assessment (HRA)

Completion: Completed by [patient / caregiver / staff-assisted]; [prior to visit / during visit].

• Self-rated health: [Positive / Negative / Declined] (If positive, briefly summarize concern.)
• Psychosocial risks: [Positive / Negative / Declined] (Summarize any positive findings related to mood, stress, loneliness, or social support.)
• Behavioral risks: [Positive / Negative / Declined] (Specify which subdomain is positive: tobacco, alcohol, activity, or nutrition.)
• ADL/IADL status: [Independent / Needs assistance / Declined] (Briefly note areas of assistance if applicable.)

(For every positive domain above, include a corresponding intervention in the Personalized Prevention Plan.)

History

(For Initial AWV, establish baseline. For Subsequent AWV, note interval changes; "reviewed and updated, no changes" is acceptable for unchanged items.)

• Past Medical History: [Relevant conditions or interval changes]
• Surgical History: [Relevant procedures or interval changes]
• Allergies: [Allergen and reaction / NKDA]
• Medications (Reconciled): [Medication list with doses] (Document reconciliation performed and source: [patient report / pharmacy records / medication bottles / EMR]. Note discrepancies resolved.)
• Pertinent Family History: [Relevant conditions]
• Current Providers/Care Team: [PCP, specialists, and other care team members]

Objective & Screenings

(AWV does not include a comprehensive physical exam. If any required screening was not performed, document reason and any alternative method used.)

Measurements: Height: [value] (Initial AWV only) | Weight: [value] | BMI: [value] | Blood Pressure: [value] (If telehealth, note values are patient-reported.)

• Cognitive Assessment: Method: [structured observation / Mini-Cog / other validated tool]; Result: [normal / abnormal / inconclusive / declined]; Plan if concern identified: [further evaluation / referral / caregiver education / safety planning].
• Depression Screening: Tool/Score: [PHQ-2 / PHQ-9 with score]; Interpretation: [negative / positive - severity]; Follow-up if positive: [safety assessment per protocol / referral / brief intervention].
• Functional/Safety: ADL/IADL: [independent / assistance needed]; Fall Risk: [negative / positive]; Hearing: [no concerns / concerns noted]; Home/Driving Safety: [no concerns / concerns noted]. Interventions for positive findings: [PT/OT referral / home safety education / device referral / medication review].
• Substance Use: Alcohol: [AUDIT-C score and interpretation]; Tobacco: [never / former / current] (If current, document cessation counseling provided.); Other substances: [screened negative / positive with intervention / not screened].
• Opioid Review: [Opioid use disorder risk, pain management, and non-opioid alternatives reviewed; PDMP checked.] (Only include if patient has current opioid prescription.)

Assessment

(List chronic conditions relevant to prevention and identified risk factors, ordered by clinical priority.)

• [Condition/Risk 1]: [Status, control, and key considerations]
• [Condition/Risk 2]: [Status, control, and key considerations]
• [Additional identified risks]: [Brief summary of falls, tobacco, obesity, depression, cognitive concern, or substance use risks]

Personalized Prevention Plan

(Organize by risk factor or goal. Ensure every positive HRA or screening finding has a corresponding intervention.)

• [Risk Factor/Goal 1]: Counseling: [personalized recommendation]; Intervention: [referral or program]; Patient Goal: [specific goal with timeframe].
• [Risk Factor/Goal 2]: Counseling: [personalized recommendation]; Intervention: [referral or program]; Patient Goal: [specific goal with timeframe].
• Lifestyle Counseling Addressed: [Topics discussed: nutrition, physical activity, sleep, weight, tobacco, alcohol, fall prevention, medication adherence as applicable].

Screening and Immunization Schedule

(Individualized to patient age, sex, and risk factors per USPSTF and CDC guidance.)

• [Service name] | Last: [date/result] | Next Due: [date] | Ordered Today: [Yes / No]
• [Service name] | Last: [date/result] | Next Due: [date] | Ordered Today: [Yes / No]
• [Immunization name] | Last: [date] | Next Due: [date/criteria] | Ordered Today: [Yes / No]

Advance Care Planning

[Performed / Offered and declined / Not addressed]. (If performed, document: discussion was voluntary; participants; topics addressed such as goals, healthcare proxy, advance directive; and outcomes. If declined, note briefly. Omit section entirely if ACP not addressed.)

Orders

• Vaccines: [Vaccines ordered]
• Labs/Imaging: [Tests ordered]
• Referrals: [Referrals placed: PT/OT, audiology, behavioral health, nutrition, tobacco cessation, etc.]

Follow-up

Next AWV: [12 months from today]. Interim follow-up: [Timeframe and purpose for abnormal findings or pending results] (Only include if applicable.)

Patient Deliverables

Personalized prevention plan and written screening schedule provided to patient via [AVS / printout / patient portal].

Separately Identifiable Problem-Oriented Visit

(Only include this section if a distinct problem-oriented E/M service was performed on the same date requiring modifier use.)

• Chief Concern: [Problem-specific reason for visit]
• Focused HPI: [Onset, duration, severity, associated symptoms, context, modifying factors]
• Focused Exam: [Pertinent findings relevant to problem]
• Medical Decision Making: [Assessment, data reviewed/ordered, risk level, treatment plan]
• Plan/Orders: [Medications, tests, referrals, patient instructions specific to problem]
• Follow-up: [Timeframe and contingencies for this problem]