Medicare Annual Wellness Visit (G0438 / G0439)

Build your Annual Wellness Visit note

Fill in what you assessed, in any order, and the engine drafts a compliant Annual Wellness Visit note for you to review and sign.

This is the visit itself. The part that saves the hour is the health risk assessment reaching the patient before they arrive, so the screens are already scored — that needs a free account.

You end up with the visit note and the screening schedule the patient takes home.

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Annual Wellness Visit · G0438 / G04390 of 10 captured

Still to capture before you bill the Annual Wellness Visit — tap one to jump to it:

Already have a visit note, scribe output or transcript? We can read it and fill in what it covers.

Health risk assessment

Required. Normally completed by the patient or family before the visit; the pre-visit form fills this section automatically.

HRA completed by

Date HRA completed

Self-rated health

Patient's own concerns and goals for the year

Psychosocial risks reported

Behavioral risks reported

Medical and family history

Past medical and surgical history

Family history (including dementia, heart disease, cancer)

Hospital stays or ED visits in the last 12 months

Allergies

Current providers, suppliers and medications

Other clinicians involved in care · Specialists, home health, behavioral health, therapy.

Suppliers and equipment · DME, oxygen, home monitoring.

Current medications, supplements and over-the-counter

Medication review completed this visit

High-risk medications identified · Anticholinergics, sedative-hypnotics, opioids, polypharmacy.

Routine measurements

Height

Weight

BMI

Blood pressure

Other measurements taken · Only what is routine for this patient. The AWV is not a head-to-toe examination.

Detection of cognitive impairment

Required at every AWV. A positive or borderline result is the trigger for a Cognitive Assessment & Care Plan (CPT 99483).

How cognition was assessed

Instrument used (if any)

Result or score

Cognitive concern identified

Family or informant reports a change

Supporting observations

Depression and mood

Screen used

Score

Result

Risk assessment documented where screen positive

Functional ability and safety

Activities of daily living

Instrumental activities (finances, medications, transport)

Falls in the last 12 months

Falls risk factors

Home safety concerns

Hearing assessed

Hearing findings

Driving

Written screening schedule

Required: a written schedule for the next 5 to 10 years, based on age, sex, risk factors and what is already up to date.

Immunizations due

Cancer screening due

Other screening due

Notes on timing and patient preference

Risk factors and conditions

Active conditions

Risk factors identified today

Treatment options and interventions discussed

Personalized health advice and referrals

Advice given

Referrals made

Follow-up plan

Supporting documents · optional · PDF or images

Attach medical history, prior reports, or other supporting evidence. They’re read to ground the report — nothing is invented. (Environment photos are captured per area above.)

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Nothing to draft from yet. Fill in what you assessed (or attach the patient’s documents) and this builds the draft from it.