What are the essential components of a comprehensive wellness visit?

Wellness Visit Progress Note Template

A comprehensive wellness visit should include structured assessment across medical, preventive, functional, and psychosocial domains, with documentation of health risk assessment, physical measurements, cognitive and depression screening, preventive service review, and personalized care planning. 1

Subjective Assessment

Health Risk Assessment

• Complete standardized HRA questionnaire covering current medical conditions, family history (diabetes, autoimmune disorders, cardiovascular disease, cancer), current medications with adherence patterns, lifestyle factors (diet, physical activity, sleep, tobacco, alcohol, substance use), and social determinants of health (food security, housing stability, transportation access, financial security) 1, 2
• Review interval medical history since last visit, including recent illnesses, hospitalizations, new symptoms, and changes in health status 2
• Assess medication-taking behavior, medication rationing due to cost, side effects, and intolerance 3
• Screen for eating patterns, weight history, and disordered eating when appropriate 1

Functional and Psychosocial Screening

• Assess functional performance and activities of daily living, particularly for patients ≥65 years using structured tools 1, 3
• Screen for cognitive impairment using Mini-Cog (sensitivity 76%, specificity 89%), General Practitioner Assessment of Cognition, or Memory Impairment Screen 1, 3
• Screen for depression using PHQ-2 or PHQ-9 and anxiety using validated tools 1, 3
• Evaluate sleep patterns, duration, and screen for obstructive sleep apnea 2, 3

Objective Assessment

Physical Measurements

• Height, weight, BMI calculation, waist circumference 1, 2
• Blood pressure measurement 1
• Physical examination focused on interval changes and age-appropriate concerns 2

Laboratory and Screening Tests

• Complete blood count with differential, comprehensive metabolic panel 1
• Lipid profile (total cholesterol, LDL, HDL, triglycerides) if not done within past year 1, 3
• Hemoglobin A1C if diabetic or at risk, if not available within past 3 months 3
• Age-appropriate cancer screening: colorectal cancer screening starting age 45, mammography biennially for women 50-74 years, cervical cancer screening per guidelines 1, 3
• Bone health assessment (calcium, vitamin D, phosphorous) when appropriate for postmenopausal women 3

Vaccination Status Review

• Review and update vaccinations per CDC age-appropriate recommendations 2, 1
• Annual influenza vaccine for all patients ≥6 months 2
• Pneumococcal vaccination (PPSV23) for patients ages 2-64 years with diabetes or high-risk conditions 1
• COVID-19 vaccination and boosters as indicated 2

Assessment and Plan

Preventive Care Planning

• Document completion of required wellness visit components including HRA, cognitive screening, depression screening, and functional assessment 1, 4
• Identify care partners, support system, and surrogate decision maker 2, 1
• Discuss advance care planning including healthcare proxy, living will, and end-of-life preferences 1, 3

Health Promotion Counseling

• Provide counseling on nutrition emphasizing AHA Step II diet principles (saturated fat reduction, cholesterol management) 2
• Discuss physical activity goals with specific recommendations for frequency and type of exercise 2
• Tobacco cessation counseling using motivational interviewing if applicable, with pharmacotherapy options 2
• Alcohol moderation counseling when indicated 2
• Weight management strategies for BMI >25 kg/m² or waist >40 inches (men) or >35 inches (women) 2

Chronic Disease Management

• Review diabetes self-management behaviors, nutrition, and glycemic targets if diabetic 2
• Assess cardiovascular risk factors: hypertension (target <140/90 mmHg, lower for diabetes/CKD), dyslipidemia (LDL target <100 mg/dL for secondary prevention), smoking status 2
• Evaluate for diabetes complications and comorbidities including retinopathy, nephropathy, neuropathy, cardiovascular disease 2

Medication Reconciliation

• Reconcile medication list with patient's actual bottles (prescription, over-the-counter, supplements), ideally 30 minutes before visit with medical assistant, pharmacist, or nurse 2
• Address medication-related problems including suboptimal drug selection, insufficient monitoring, undertreatment, and suboptimal dosing 5

Referrals and Follow-up

• Provide referrals to health education, prevention counseling services, diabetes self-management education, cardiac rehabilitation, or specialty care as indicated 2, 1
• Schedule follow-up visits at least every 3-6 months for chronic disease management, annually for wellness visits 2
• Establish collaborative care plan with patient incorporating their preferences, values, goals, and health priorities 2

Common Pitfalls to Avoid

• Do not skip cognitive screening even if patient appears intact, as Medicare specifically requires this assessment and early detection facilitates planning 1
• Do not overlook functional assessment in patients ≥65 years, as this identifies geriatric syndromes critical for care planning 1
• Do not substitute brief sports physicals or focused visits for comprehensive preventive examinations, as full preventive services are covered and expected 6, 3
• Do not neglect mental health screening, as depression and anxiety screening are critical wellness visit components 6, 3
• Do not delay colorectal cancer screening beyond age 45, as guidelines have lowered the recommended starting age from 50 1
• Do not focus solely on physical health while neglecting behavioral and social aspects, including social determinants of health 6, 3