01 / ADAPTABLE OUTLINE
What to document
Health risk assessment & history
Health risk assessment findings; medical and family history; medications; treating clinicians; and the patient's priorities.
Function, cognition & mood
Daily function, safety, falls, cognitive concerns, mood assessment, and the methods and findings of any completed screening.
Measurements & prevention review
Required measurements, screening and immunization history, individual risk factors, and gaps confirmed from available records.
Personalized prevention plan
Written screening schedule, risk-reduction recommendations, referrals, patient preferences, and who will arrange and track follow-up.
02 / WORKED EXAMPLE
Prevention-planning excerpt from a wellness visit
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
History & risk review
A 68-year-old woman presents for an annual wellness visit. The health risk assessment and medication list were reviewed. She reports independence with daily activities, no falls in the past year, and no concerns about memory. Her care team and preventive history were updated.
Prevention discussion
Prior records were reviewed. Breast and colorectal cancer screening were confirmed due for this patient. Screening options and preferences were discussed; she prefers mammography and colonoscopy. Referral and order arrangements were reviewed with her.
Personalized plan
Mammogram ordered and gastroenterology referral placed for screening colonoscopy. These services have not yet been completed. The patient will contact the office if she has not received scheduling information within two weeks. A written prevention plan was provided and reviewed.
A common documentation question
Does using this template establish a billing code?
No. A template does not establish eligibility, medical necessity, completed service elements, or a billing level. Check the current payer requirements and code only the services actually performed and documented.
GO DEEPER / CONDITION-SPECIFIC PLANS
Treatments, doses & follow-up
A note style does not determine a treatment. Explore the condition-specific examples for sourced adult dosing references, clinical reasoning, and follow-up plans.
TRY AN INTERACTIVE EXAMPLE
PHQ-9, from responses to documentation.
Select inputs, see the score, and preview the documentation. Missing answers stay incomplete.