Headings
Health risk assessment · History update · Medications · Functional and cognitive screen · Depression screen · Vital signs · Preventive schedule · Advance care planning · Plan
When to use it
Use this for the yearly Medicare wellness visit, where the goal is prevention and planning rather than treating a problem. It walks through the required risk, cognitive and mood screens, then builds a written preventive schedule and advance care plan. If the patient also raises a new complaint, document that separately in an acute or problem note.
Example
Fictional example
Health risk assessment
R.M., 72. Lives alone. Walks 30 minutes daily. Never smoked. One fall in the past year, no injury.
History update
Right cataract surgery in March. No hospital stays.
Medications
Atorvastatin 20 mg daily. Lisinopril 10 mg daily. No new supplements.
Functional and cognitive screen
Independent in all daily activities. Mini-Cog 5 of 5. Timed Up and Go 11 seconds.
Depression screen
PHQ-2 score 0.
Vital signs
BP 128/76, pulse 70, BMI 26.4.
Preventive schedule
Colonoscopy due 2027. Second shingles vaccine dose due now. Bone density scan ordered.
Advance care planning
Daughter named as health care proxy. Proxy form given to complete at home.
Plan
Refer to community balance class. Shingles dose 2 today. Return in 12 months.