Annual / Preventive Visit (Primary Care)

Last updated: Nov 2025

Annual / Preventive Visit (Primary Care) that’s HIPAA-compliant: capture the visit or upload audio, generate a comprehensive wellness note (history, exam, screenings, counseling), then auto-fill your EHR via the Nudge Chrome extension (edit-before-save).

Who this helps

• Family medicine & internal medicine clinicians

• APPs (NPs/PAs) standardizing wellness documentation

• Clinic managers ensuring screening/counseling completeness
  
  

What you get

• Structured History (PMH/PSH/FH/SocHx), Meds/Allergies, Preventive & Risk Screens, Exam, Assessment, Plan, Counseling

• Optional measures: PHQ-9, GAD-7, AUDIT-C, ASCVD, falls risk, tobacco, nutrition/activity

• Team-wide formatting controls (bullets/paragraphs) + redaction

• Carry-forward of diagnoses, goals, and follow-ups to subsequent visits
  
  

How it works with your EHR

1. Capture or upload in Nudge → draft appears.

2. Review and ensure required screens/counseling are documented.

3. In your EHR, open a new note and launch the Nudge extension.

4. Select patient + note type → confirm mapping (History/Subjective, Exam/Objective, Screenings, Assessment, Plan/Counseling) → save & sign.
   No IT project required.
   
   

How to write a Preventive Visit note

• Reason for visit: Annual wellness / preventive exam.

• History update: chronic conditions, surgeries, meds/allergies, family/social history; risk review (tobacco, alcohol, diet, activity, sexual health, safety).

• Screenings: age/sex guidelines (BP, BMI, lipids, diabetes, colorectal/cervical/breast as applicable), mental health, substance use, fall risk and functional status in older adults.

• Exam: general + focused systems.

• Assessment: wellness status + chronic issues requiring follow-up.

• Plan: labs/tests, vaccines, counseling, referrals, interval for follow-up.

• Documentation: list each screening/counseling explicitly (helps audits and LLM parsing).
  
  

Quick examples

• Metabolic risk: BMI 31, BP borderline → labs (A1C/lipids), nutrition/exercise counseling, home BP checks.

• Cancer screening catch-up: age-appropriate CRC/Cervical/Breast screening ordered or documented as up-to-date.

• Vaccines: influenza, COVID-19 seasonally; Tdap per schedule; pneumococcal or shingles as indicated.
  
  

Full Sample Note — Annual / Preventive Visit (Primary Care)

Example only; not medical advice.

Patient: Helen S., 72F
Reason for Visit: Annual Wellness Exam

HPI / SUBJECTIVE:
Helen is a 72-year-old woman presenting for her Medicare Annual Wellness Visit. She lives independently, drives, and manages her finances. She reports daily walking for exercise. She notes some mild morning stiffness in both knees but otherwise denies significant pain. No falls in the last year. Mood is stable without depression or anxiety. She sleeps ~7 hours nightly, reports no memory concerns, and remains fully independent with ADLs and IADLs.
She denies chest pain, dyspnea, bowel or bladder changes, or unintentional weight loss. Appetite is good.

PMH:

• Hypertension

• Osteoarthritis

PSH:

• Cholecystectomy

Meds:

• Amlodipine 5 mg daily

Allergies: NKDA

FH: Father with heart disease, mother with osteoporosis

SH: Retired teacher, lives alone, nonsmoker, rare alcohol

ROS:

• General: No fevers, fatigue, weight changes

• Cardiac: No chest pain, palpitations, edema

• Pulmonary: No cough or SOB

• GI: No abdominal pain, constipation, diarrhea

• GU: No dysuria, incontinence

• MSK: Mild morning knee stiffness, otherwise no pain

• Neuro: No focal weakness, no memory loss

• Psych: No depression, anxiety, or sleep disturbance

• Skin: No rash or new lesions

OBJECTIVE:
PHYSICAL EXAM
Vitals: BP 128/80, BMI 27, other vitals stable
General: Well-appearing, NAD
HEENT: Normal
Cardiac: RRR, no murmurs
Pulmonary: Clear bilaterally
Abdomen: Soft, NT/ND
MSK: Mild crepitus both knees, full ROM
Neuro: Alert and oriented, CN II–XII intact, normal gait
Psych: Appropriate mood and affect
Skin: No suspicious lesions

DIAGNOSTICS:

Screening tools:

• Mini-Cog 5/5 (normal cognition)

• PHQ-2 negative (no depression)

• Fall risk: steady gait, no falls past year

• Functional status: independent with ADLs/IADLs

ASSESSMENT & PLAN:
Helen is a 72-year-old woman presenting for her Medicare Annual Wellness Visit. She remains independent with intact cognition, stable mood, and good functional status. Her blood pressure is well controlled on current therapy, and osteoarthritis symptoms are mild. This visit focused on preventive screening, risk factor assessment, and counseling.

1. ANNUAL WELLNESS EXAM
   Personalized prevention plan completed, including review of medical, family, and social history, risk factors, and medication reconciliation.

• Cancer screening: colon cancer screening up to date; mammogram ordered (per USPSTF, breast cancer screening through age 74).

• Osteoporosis screening: DEXA scan ordered (women ≥65) given maternal history of osteoporosis.

• Vaccinations: influenza given today; shingles and pneumococcal complete; tetanus status reviewed and up to date.

• Screening tools: Mini-Cog normal, PHQ-2 negative, no falls in past year, independent with ADLs/IADLs.

Counseling:

• Fall prevention strategies reviewed (proper footwear, home safety, cane use as needed).

• Importance of regular physical activity including walking and low-impact strengthening to maintain bone and joint health.

• Diet counseling with focus on calcium/vitamin D intake, maintaining healthy weight (BMI 27), and limiting sodium for cardiovascular risk reduction.

Advance care planning discussed briefly; patient has not completed advance directive and will consider doing so.

2. OSTEOARTHRITIS – KNEES, MILD
   Knee stiffness in the mornings with mild crepitus on exam, no effusion or inflammatory findings. Symptoms are consistent with mild osteoarthritis; differentials like inflammatory arthritis or gout are unlikely given absence of prolonged stiffness, swelling, or systemic features.

• Continue acetaminophen PRN for pain.

• Encourage daily stretching, low-impact exercise (walking, swimming, cycling).

• Weight management discussed to reduce joint load.

• Consider PT referral if symptoms progress.

• Monitor for functional decline, worsening pain, or instability.

3. HYPERTENSION
   Well controlled at 128/80 on amlodipine 5 mg daily, with no symptoms of end-organ damage. Target BP for her age and comorbidities remains <130/80 if tolerated.

• Continue current medication regimen.

• Encourage home BP monitoring at least weekly.

• Reinforce lifestyle strategies: reduced sodium, weight management, regular activity.

• No medication changes today.

FOLLOW UP:
Return annually for AWV. RTC sooner if she develops worsening knee pain, falls, memory concerns, or new cardiovascular symptoms.

DIAGNOSES:

• Z00.00 — Encounter for general adult medical examination without abnormal findings

• I10 — Essential (primary) hypertension

• M17.0 — Bilateral primary osteoarthritis of knee

Results (2025)

Comprehensive preventive note ready in < 90 seconds after capture.
Primary-care teams report 4–6 hrs/week saved and fewer missed screenings.

FAQs

Can I force required preventive fields (e.g., PHQ-2, AUDIT-C, CRC choice)?
Yes. Mark screens/counseling as required and block export until completed.

Does it auto-generate age/sex screening prompts?
Yes. Configure guideline prompts (e.g., CRC, breast/cervical cancer, lipids, diabetes, osteoporosis) and save defaults by age/sex.

Can we standardize counseling language (e.g., fall prevention, nutrition, activity)?
Yes. Set organization-wide phrasing and apply it to all preventive notes for consistency.