Preventive Care Visit Note (Wellness)

Date: [Date]

Visit Type: [Preventive Medicine Visit / Medicare AWV / IPPE / Other]

Patient: [Name, age, sex]

Provider: [Provider name, credentials]

AWV Status: [Initial / First Subsequent / Subsequent] (Include only for Medicare AWV)

Reason for Visit & Interval History

[Preventive purpose, interval events, and patient goals] (2-4 sentences. Begin with why the patient is here for preventive care; note time since last wellness visit and significant interval events such as hospitalizations or new diagnoses; include patient-stated goals if any. If non-preventive problems will also be evaluated, note that a separate problem-oriented section follows.)

Health Risk Assessment

(Include only screenings actually performed today with results. For Medicare visits, address at minimum: depression, cognitive concerns, functional status/fall risk, and substance use. Note positive screens requiring follow-up. If declined or deferred, note briefly. If history unknown, document action taken.)

• Depression: [Tool, score, interpretation]
• Cognitive concerns/screen: [Concerns present/absent; tool and result if screened]
• Functional status & fall risk: [ADL/IADL status; fall risk screen result]
• Substance use: [Tobacco status; alcohol screen tool/result; other substances if assessed]
• Other screenings: [Additional screenings performed with tool and result] (Include only if applicable)
• History gaps: [Unknown history documented; records requested or registry queried] (Include only if applicable)

Objective

• Vitals: [BP, HR, weight, BMI, others as relevant]
• Exam: [Pertinent findings from exam performed; note if limited vs comprehensive] (For AWV, document only elements actually examined)
• Data: [Labs, imaging, or point-of-care results reviewed today with dates] (Include only if reviewed)

Assessment

[Encounter type and relevant active conditions] (2-4 sentences. State encounter type with AWV status if applicable. List active conditions affecting preventive decisions and any risk factor diagnoses addressed such as tobacco use disorder or obesity.)

Preventive Care Plan

(Include only items relevant to this patient. Document shared decision-making briefly when required.)

• Screenings: [Screening name, indication, status (ordered/scheduled/not indicated), patient decision (accepted/declined/deferred), timeframe]
• Immunizations: [Vaccines administered today with date and VIS provided; vaccines due/planned with timeframe; if history unknown, note plan to treat as incomplete per guidelines]
• Counseling & Referrals: [Topics addressed with specific goals or patient commitments; referrals placed with service and reason]
• Follow-up: [Routine preventive follow-up timing; earlier follow-up if needed for abnormal findings or pending results; how results will be communicated]

Separately Identifiable Problem-Oriented Evaluation

(Complete only if a distinct problem-oriented evaluation was performed in addition to preventive services. Document separately to support modifier 25 billing.)

Subjective

[Focused history for the problem: onset, duration, severity, modifiers, associated symptoms, pertinent ROS]

Objective

[Focused exam findings and relevant data for the problem]

Assessment & Plan

• [Problem: diagnosis] — [clinical assessment] — [plan: testing, treatment, referrals, follow-up]