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Autotext Dot Phrases for Cerner EHR

All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Do not merely copy and paste a prewritten note element into a patient's chart - "cloning" is unethical, unsafe, and potentially fradulent.

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Initial Medicare Annual Wellness Visit Checklist

HPI/Family /Social History

Perform patient reported Health Risk Assessment

Staying Healthy AssessmentSenior version

Medical and Family History – By history – often in Cerner

Current Providers List - Document

Medications List – In Cerner

Offer Advanced Care Planning at the patient’s discretion – POLST, Advanced Directive


Review Opiods, evaluate pain, screen for OUD if needed

SBIRT form– (Screening, Brief Intervention, Referral to Treatment)


Objective Data

  1. Measure Height Weight Vitals, BMI, Vision - Routine

  2. Assess and document Cognitive Function by any of the following;

Direct Observation

Family Members

MOCA or other cognitive test

  1. Assess Depression/Mood Disorders Risk (On SBIRT)

PHQ-2 or PHQ-9

  1. Assess Functional Ability or Safety (Fall risk) - (On Staying Healthy Assessment)

    1. Direct Observation or screening tool in all of the following areas;

· Ability to perform ADLs (On Staying Healthy Assessment)

  • Do you have problems with cooking, cleaning and groceries?

  • Taking medications?

  • Bathing?

  • Finances?


· Fall Risk – (On Staying Healthy Assessment)

· Get up and Go Test

  • Initial Assessment - From sitting position, stand without using their arms for support. • Walk10 feet, turn, and return to the chair. • Sit back in the chair without using their arms for support. Individuals who have difficulty completing the above in less than 10 seconds or demonstrate unsteadiness performing this test require further assessment.

  • Follow-up Assessment - Ask the person to: • Sit. • Stand without using their arms for support. • Close their eyes for a few seconds, while standing in place. • Stand with eyes closed, while you push gently on his or her sternum. • Walk a short distance and come to a complete stop. • Turn around and return to the chair. • Sit in the chair without using their arms for support

  • Follow-Up Assessment Observations

• Is the person steady and balanced when sitting upright? Yes † No †

• Is the person able to stand with the arms folded? Yes † No †

• When standing, is the person steady in narrow stance? Yes † No †

• With eyes closed, does the person remain steady? Yes † No †

• When nudged, does the person recover without difficulty? Yes † No †

• Does person start walking without hesitancy? Yes † No †

• When walking, does each foot clear the floor well? Yes † No †

• Is there step symmetry, with the steps equal length and regular ? Yes † No †

• Does the person take continuous, regular steps? Yes † No †

• Does the person walk straight without a walking aid? Yes † No †

• Does the person stand with heels close together? Yes † No †

• Is the person able to sit safely and judge distance correctly? Yes † No †

• Is the person obviously fearful or anxious during assessment? Yes † No †


· Hearing impairment – Whisper test, formal hearing test

  • The Whisper Test

    1. Stand 1-2 feet behind patient so they can’t read your lips.

    2. Instruct patient to place one finger on tragus of left ear to obscure sound.

    3. Whisper word with 2 distinct syllables towards patient's right ear.

    4. Ask patient to repeat word back.

· Home safety

  • Brief Screening

    • Have you fallen in the past year?

    • Do you feel unsteady when standing or walking?

    • Are you worried about falling?

Brief Assessment – consider physical therapy referral or PM&R referral

Gait, strength, balance tests

Identify medications taken that increase falls risk

Ask about home hazards

Consider measuring orthostatic blood pressure

Check visual acuity

Assess feet and footwear

Assess Vitamin D intake

Identify comorbidities that increase falls


Assessment and Plan


Identify a Problem List and Risk Factors and your treatment/interventions.


Provide a Written Health Maintenance checklist for the next 5-10 years (Eg. USPTF)



Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs.


Include referrals to educational and counseling services or programs aimed at:

Community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including:

o Fall prevention

o Nutrition

o Physical activity

o Tobacco-use cessation

o Weight loss

o Cognition


Refer as needed for addiction services.


Coding


G0438 – Initial Annual wellness visit; includes a personalized prevention plan of service, within the first 12 months of starting Medicare

G0439 – Subsequent Annual wellness visit, includes a personalized prevention plan of service, at least 12 months after the initial wellness visit


Can use any diagnosis but need a diagnosis – (Well Adult or similar would be a good choice)


You can also bill for screening tests (colon cancer, breast cancer, dexa, vaccines etc.) under this visit or at a future visit, does not need to be a screening, be sure to use the diagnosis code for each screening test Eg. Screening for malignant neoplasm colon, screening for malignant neoplasm breast, post-menopausal state, need for vaccination)

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