What components are required to be documented in a general annual wellness exam?

Required Documentation for a General Annual Wellness Exam

The annual wellness exam should include comprehensive documentation of demographics, family history, health history, physical examination findings, and appropriate screening assessments to evaluate overall health status and identify potential health risks.

Demographics and Basic Information

• Sex, birthdate, race/ethnicity, education level 1
• Contact information and emergency contacts 1

Comprehensive Health History

• Family history: Document diseases in first-degree relatives including:

  • Stroke, vascular disease, myocardial infarction
  • History of dementia and other neurological diseases
  • Age at death and age of significant health events 1

• Personal medical history:

  • Cardiovascular conditions (myocardial infarction, arrhythmia, heart failure, angina, peripheral artery disease)
  • Cerebrovascular disease (stroke, TIA)
  • Chronic conditions (hypertension, hyperlipidemia, diabetes mellitus)
  • Surgeries and procedures
  • Complete medication list including over-the-counter preparations 1
  • Immunization history and needs 1

• Social and behavioral history:

  • Tobacco, alcohol, and substance use
  • Diet and eating patterns
  • Physical activity and sleep behaviors
  • Social determinants of health (food security, housing, transportation) 1

Physical Examination

• Vital signs: height, weight, BMI, blood pressure (including orthostatic if indicated) 1
• Cardiovascular examination 1
• Pulmonary examination 1
• Skin examination (including inspection for concerning lesions) 1
• Neurological assessment including cognitive screening for older adults 1
• Comprehensive foot examination (especially for patients with diabetes) 1

Laboratory and Diagnostic Testing

• Document results of recent relevant laboratory tests:
  • Lipid profile
  • Blood glucose or A1C (especially for those at risk)
  • Complete blood count
  • Liver function tests
  • Kidney function (serum creatinine, eGFR)
  • Urinalysis 1

Screening and Risk Assessments

• Depression, anxiety, and psychological distress screening 1
• Cognitive assessment (for adults 65 and older) 1
• Functional status assessment for older adults 1
• Quality of life assessment using standardized questionnaires 1

Treatment Plan and Follow-up

• Document a patient care plan with priorities for risk reduction 1
• Include short-term and long-term goals 1
• Preventive care recommendations and screenings due 2
• Medication adjustments and management 1
• Referrals to specialists if indicated 1

Common Pitfalls to Avoid

1. Inadequate documentation of preventive services: Ensure all recommended age-appropriate screenings are addressed and documented.
2. Missing medication reconciliation: Document all current medications with dosages and adherence assessment.
3. Overlooking functional assessments in older adults: For patients 65 and older, document cognitive and functional assessments.
4. Failing to address social determinants of health: Document housing stability, food security, and other social factors that impact health.
5. Incomplete follow-up plans: Clearly document the plan for addressing any identified health concerns.

While some evidence questions the mortality benefit of general health checks 2, they remain valuable for disease detection, risk factor control, and preventive service delivery. The most recent evidence shows wellness visits are associated with improved chronic disease recognition, better risk factor control, and increased uptake of preventive services 2.