This stuff is a little dated, so you might want to check against current requirments by Medicare.
HPI:
This patient is here for %his Initial Annual Wellness visit with Medicare. %He is out of the time limit for the Initial Preventive Exam (Welcome to Medicare). %FNAME reports being in good health.
Other Providers:
Vision Test: Left ( ) Right ( )
PMH:
Pneumovax (rec once >65):
Tdap (rec every 10 years):
Influenza (rec yearly):
Mammogram (rec yearly females):
PSA (rec yearly males): [no longer covered]
DEXA (rec q2 years):
Colon CA Screening:
Due Date for Next:
Advanced Directive: Y/N
Tobacco Use (rec no smoking): Y/N
(smoking increases risks of death, MI, CVA, and CA)
Assessment:
# ROUTINE GENERAL MEDICAL EXAMINATION AT A HEALTH CARE FACILITY (V70.0): AWV: Initial, peformed. The plan of care is as follows in the plan section.
Cognition: Recall of three words normal.
Depression Score: Patient has no depression
Functional Ability: Normal Up & Go test, normal ADL screen, normal walk safety screen, normal hearing screen.
All of questions %Mr %LNAME had were answered.
V77.1, V77.91
Initial: G0438
Subsequent: G0439
Plan:
Personalize Prevention Plan of Service (PPPS)
Vaccines (PNA once >65, Inf yearly, Hep B med/high risk):
Prostate Ca Screen (annually to 75 yo):
Colon CA Screen (to 75 yo):
Glaucoma Screen:
CVS Screening Labs (every 5 years):
DM Education:
DM Screening Labs (every 3 years, prediabetic 6mo):
AAA (once for men 65-75 smoked >100 cigs, anyone with FH of AAA, may be only covered at Welcome Visit):
HIV (inc risk patients): n/a
Smoking Cessation (8 cessions per year): Smokers should quit: this increases risk for lung disease and cancers, early death.
Subsequent AWV: Recommended 1 year.
