Documenting Wellness Visits vs Problem Visits in Practice

What's the main goal of a wellness visit?

In a wellness visit, your main goal is to focus on preventive care. These visits are about maintaining health and catching potential issues early. You'll cover things like immunizations, screenings, and lifestyle advice. It's more about the big picture of the patient's health rather than addressing specific complaints.

How do you document a wellness visit?

For wellness visits, documentation should include:

• Patient history: Update any changes since the last visit.
• Screenings and preventive measures: Note any tests or immunizations given or scheduled.
• Counseling and education: Record lifestyle advice on diet, exercise, smoking cessation, etc.
• Assessment: Include a general health assessment and any findings from the physical exam.

Remember, the focus is on prevention and health maintenance, so your notes should reflect that.

What differentiates a problem visit?

A problem visit is about diagnosing and managing specific issues. This could be anything from a sore throat to a chronic condition like diabetes. Here, your focus is on the patient's complaint and how to address it.

How do you document a problem visit?

For problem visits, your documentation should include:

• Chief complaint: Clearly state why the patient is there.
• History of present illness: Detailed notes on the issue's onset, duration, and characteristics.
• Physical exam: Document findings that relate to the problem.
• Assessment and plan: Diagnosis and treatment plan, including any prescriptions or follow-up appointments.

Your notes should be specific to the patient's issue and show a clear plan for management.

Can you give an example of each?

Sure! Let's say you have a 45-year-old patient.

Wellness visit: The patient is there for an annual check-up. You update their medical history, perform routine screenings, discuss diet and exercise, and give a flu shot.

Problem visit: The same patient comes in complaining of persistent knee pain. You document their symptoms, perform a focused physical exam on the knee, and create a treatment plan that might include imaging or a referral to a specialist.

In both cases, clear and accurate documentation supports better patient care and ensures you're meeting all necessary guidelines.