Medicare Annual Wellness Visit Support Note (HRA Inputs)

Date(s) of Service: [Date HRA completed; AWV encounter date if different]

AWV Type: [Initial / Subsequent]

Location/Modality: [in-person / telehealth / telephone]

Author: [Name, credentials, role]

Data Sources: [patient self-report / caregiver report / chart review / patient portal / external records]

Interpreter/Accommodations: [Language, interpreter or assistive services used, accessibility accommodations] (Only include if applicable)

HRA Administration

Completion Status: [complete / partial / declined]

Mode: [patient portal / paper / phone / in-person interview]

Completed By: [patient / caregiver-proxy / staff-administered]

Notes: [Accommodations provided, assistance needed, barriers, reasons if partial or declined] (Omit if none)

Full HRA Location: [File path, link, or media tab reference where complete questionnaire is stored]

HRA Findings Summary

(For each domain, document: patient response or screening result; risk flag; and staff action taken. Use patient's own words for goals. Flag urgent safety concerns for same-day clinician awareness.)

Self-Rated Health & Goals

• Patient response: [Self-rated health status; stated priorities and goals for the coming year]
• Risk flag: [negative / positive / needs clarification]
• Staff action: [Education provided; resources shared; clinician notified if needed]

Psychosocial/Emotional

• Patient response/screening: [Stress, isolation, social support, life satisfaction; tool and score if used]
• Risk flag: [negative / positive / needs clarification]
• Staff action: [Resources offered; referrals recommended or initiated; clinician notified if indicated]

Behavioral Risks

• Tobacco: [Status; readiness to quit] — Risk flag: [negative / positive / needs clarification] — Staff action: [Counseling or resources; clinician notification if indicated]
• Alcohol: [Screening tool and score] — Risk flag: [negative / positive / needs clarification] — Staff action: [Brief education; referral recommendation if indicated]
• Nutrition/Oral health: [Flags reported or observed] — Risk flag: [negative / positive / needs clarification] — Staff action: [Education; dental or nutrition referral per protocol]
• Physical activity: [Frequency, duration, intensity] — Risk flag: [negative / positive / needs clarification] — Staff action: [Activity counseling or resources]
• Home and motor vehicle safety: [Seatbelt and helmet use; home hazards] — Risk flag: [negative / positive / needs clarification] — Staff action: [Safety education or resources]

Functional Status (ADLs/IADLs)

• Patient response/observation: [Independence in self-care and instrumental activities; assistive devices; caregiver involvement; recent changes]
• Risk flag: [negative / positive / needs clarification]
• Staff action: [Resources or referrals; clinician notification if decline noted]

Fall Risk & Safety

• Patient response/screening: [Falls in past 12 months with injury status; balance or gait concerns; home safety issues; hearing concerns; tool name and result if used]
• Risk flag: [negative / positive / needs clarification]
• Staff action: [Fall prevention education; assistive device guidance; referral recommendation; clinician notified for positive screen or injuries]

Cognition

• Concerns/screening: [Patient or family concerns; staff observations; screening tool, score, and interpretation]
• Screen interpretation: [positive / negative] (Document screen interpretation only; do not assign a diagnosis)
• Staff action: [Clinician notified if positive; education or resources provided]

Depression/Mood

• Tool and score: [Tool used; score; positive / negative]
• Safety: [Suicidal ideation response per clinic safety protocol] (If positive screen, indicate whether clinician notified)
• Staff action: [Education or resources; urgent escalation if indicated]

Substance Use Risk

• Screening status: [completed / declined] (Include tool and result if completed)
• Risk factors identified: [Findings or patient report]
• Staff action: [Education; referral recommendations per protocol; clinician notified if indicated]

Opioid Review (Include only if patient has current opioid prescription)

• Current opioid: [Medication name, dose, frequency per med list]
• Pain/Function: [Pain severity; functional impact]
• Education provided: [Safe use, storage, disposal; overdose risk; naloxone if applicable]
• Staff action: [Referral considerations; clinician notified if concerns]

SDOH Needs (Include only if SDOH assessment performed)

• Tool used: [SDOH screening tool name]
• Identified needs: [Domains and details]
• Resources/referrals: [Resources provided; referrals initiated or recommended] (Note dates if completed on different day than AWV)

Preventive Services Due (Inputs for Clinician)

(List best-available care gaps. For each item include: service name; last done date and result or "Unknown—records requested"; status; and basis. If patient reports an outside test without date or result, note "completed at outside facility; date/result unknown." Do not assume due when unknown.)

• Immunizations: [Influenza, pneumococcal, shingles, Tdap, COVID-19 — status and dates as available]
• Cancer screenings: [Colorectal, breast, cervical, lung if risk-based — status and dates as available]
• Bone health: [DXA status and date if applicable]
• Cardiometabolic: [Blood pressure, diabetes screening, lipids — status and dates as available]
• Vision/Hearing: [Exam dates and status as available]

Risk Factors & Recommended Actions

(List identified risks in priority order: 1) safety-critical, 2) high-impact modifiable risks, 3) preventive care gaps, 4) support needs. Use non-diagnostic wording for risk labels.)

• Risk 1: [Risk label] — Evidence: [Tool, score, patient report, or observation] — Recommended intervention: [For clinician consideration] — Patient readiness: [ready / ambivalent / not ready]
• Risk 2: [Risk label] — Evidence: [Details] — Recommended intervention: [Details] — Patient readiness: [Status]
• Risk 3: [Risk label] — Evidence: [Details] — Recommended intervention: [Details] — Patient readiness: [Status]

(Add additional risks as needed)

Clinician Review & Attestation

Action Items Requiring Clinician Attention:

• [ ] Positive screens needing assessment: [List screens and domains]
• [ ] Care gaps requiring orders/referrals: [List items]
• [ ] Safety alerts: [List if any]
• [ ] Items pending outside records: [List requested records or tests]
• [ ] Non-preventive concerns raised: [List if any] (May warrant separate E/M)

Clinician Attestation:

• [ ] Reviewed HRA inputs and incorporated findings into AWV Personalized Prevention Plan
• [ ] Reviewed positive screens and addressed or ordered follow-up as appropriate
• [ ] Confirmed screening schedule and risk factor list updated

(This support note documents HRA completion and findings for the clinician-led AWV. Staff should record patient-reported information, screening results, and observations; flag positive screens and care gaps; and provide education and resources per protocol without assigning diagnoses. When information is missing or uncertain, document what is unknown and that clinician verification is needed. The signing clinician incorporates these inputs into the final AWV Personalized Prevention Plan and billing documentation.)