Essential Components for Annual Wellness Visit (AWV) Templates
An Annual Wellness Visit template should include comprehensive assessment sections for medical history, physical examination, preventive screenings, immunizations, risk factor evaluation, and personalized care planning to optimize patient morbidity, mortality, and quality of life outcomes.
Core Components for AWV Templates
Patient Assessment and History
- Complete medical history review including:
- Social history assessment:
- Tobacco, alcohol, and substance use
- Diet and exercise patterns
- Living situation and social support
- Occupation
- Social determinants of health (housing, transportation, food security) 2
Physical Examination
- Vital signs (blood pressure, heart rate, respiratory rate, temperature)
- Height, weight, BMI calculation
- Cardiovascular assessment (heart sounds, peripheral pulses)
- Respiratory assessment
- Neurological assessment including cognitive function screening 3
- Musculoskeletal assessment including fall risk evaluation
- Skin examination 1, 2
Preventive Screenings and Risk Assessments
- Age-appropriate cancer screenings (breast, colorectal, cervical, lung, prostate)
- Cardiovascular risk assessment using Pooled Cohort Equations 1
- Depression screening
- Cognitive impairment assessment 3
- Fall risk assessment
- Substance use screening
- Domestic violence screening
- Diabetes risk assessment 1, 2
Immunization Review and Planning
- Annual influenza vaccination status
- Pneumococcal vaccination status (PCV13, PPSV23)
- Tetanus-diphtheria-pertussis vaccination status
- Herpes zoster vaccination status
- Hepatitis B vaccination status for at-risk patients
- COVID-19 vaccination status 1
Health Promotion and Education
- Nutrition counseling
- Physical activity recommendations
- Tobacco cessation counseling if applicable
- Alcohol use counseling if applicable
- Weight management strategies if applicable
- Sleep hygiene education 2
Personalized Prevention Plan
- Prioritized list of health risks
- Specific, measurable, achievable goals based on patient priorities
- Recommended preventive services with timeframes
- Referrals to specialists as needed
- Follow-up plan and schedule 1, 2
Implementation Considerations
Documentation Requirements
- Use language that is neutral, nonjudgmental, and based on facts
- Employ strength-based, respectful, and inclusive language
- Document using person-centered terminology (e.g., "person with diabetes" rather than "diabetic") 1
Billing and Coding Considerations
- Appropriate use of AWV G-codes (G0438 for initial visit, G0439 for subsequent visits)
- Documentation to support medical necessity
- Consideration of same-day billing options when health problems are identified during AWV 1, 4
Special Population Considerations
Patients with Diabetes
- Assessment of current glycemic control (A1C values and trends)
- Blood glucose monitoring patterns
- Hypoglycemia awareness and frequency
- Microvascular and macrovascular complication screening
- Foot examination 1, 2
Patients with Cardiovascular Disease
- Assessment of cardiovascular symptoms
- Medication adherence review
- Risk factor modification strategies
- Lifestyle modifications 1
Older Adults
- Comprehensive geriatric assessment
- Polypharmacy review
- Functional status assessment
- Advanced care planning discussion 5
Common Pitfalls to Avoid
- Failing to distinguish between AWV and problem-focused visits
- Not addressing preventive services due to time constraints
- Overlooking cognitive assessment, which is a required element 3, 6
- Missing opportunities for same-day management of identified issues 1
- Neglecting to create a personalized prevention plan 1
By implementing a comprehensive AWV template that addresses these components, healthcare providers can deliver high-quality preventive care, identify health risks early, and develop personalized prevention plans that improve patient outcomes.