SOAP Note Example for a Medicare Annual Wellness Visit

What is a Medicare Annual Wellness Visit (and how is it different from a physical)?

The AWV is a covered preventive service for Medicare beneficiaries focused on building or updating a prevention plan. It is not a head-to-toe physical and is not driven by a chief complaint. The goal is to assess risk, screen, and plan, so your SOAP note should read like a preventive roadmap.

• Preventive, not problem-focused: no required comprehensive exam.
• Plan-oriented: the deliverable is a written, personalized prevention plan.
• Recurring: typically an initial visit followed by subsequent AWVs over time.
• If you also manage an active problem in the same encounter, that work is documented and billed separately from the AWV.

What must be documented for a Medicare Annual Wellness Visit?

Medicare specifies elements that should be reflected in the record. A good SOAP note for an AWV maps these into the standard format so nothing is missed.

• Health Risk Assessment (HRA): self-reported health status, behavioral risks, and functional ability.
• Medical and family history review and update.
• Current providers and medications (including supplements).
• Vital signs and measurements (height, weight, BMI, blood pressure).
• Cognitive impairment detection through direct observation and patient/informant input.
• Depression and mood screening and review of functional/safety risks (falls, ADLs).
• Screening schedule and a written personalized prevention plan with referrals and advance care planning when appropriate.

How do AWV requirements fit into the SOAP format?

The SOAP structure adapts cleanly if you treat prevention as the "problem." Use Subjective for the HRA and history, Objective for measurements and standardized screens, Assessment for a risk-stratified problem list, and Plan for the personalized prevention plan.

• S = HRA, history, social and behavioral risks.
• O = vitals, BMI, cognitive/depression/fall screen results.
• A = updated problem list plus identified risks and overdue screenings.
• P = screening schedule, referrals, counseling, and the written plan given to the patient.

A SOAP note example for a Medicare Annual Wellness Visit

Here is a concrete, generic template you can adapt. It includes the typical AWV elements without any acute complaint driving the encounter.

VISIT TYPE: Medicare Annual Wellness Visit (subsequent) — preventive

S (SUBJECTIVE)
HRA completed by patient. Reports stable overall health, no new symptoms.
Lives independently with spouse; performs all ADLs/IADLs without assistance.
Behavioral risks: former smoker (quit 8 yrs); alcohol 1-2 drinks/wk;
  walks ~20 min most days; diet self-rated "fair."
Mood: PHQ-2 negative. No falls in past year. No safety concerns at home.
Meds reviewed and reconciled, including OTC and supplements.
Family/medical history reviewed and updated; current providers confirmed.
Advance care planning: has health care proxy; copy requested for chart.

O (OBJECTIVE)
Ht, Wt, BMI recorded; BP and pulse recorded.
Cognitive screen: no impairment detected on observation/brief screen.
Depression screen: negative. Functional/fall-risk screen: low risk.
Vision/hearing self-report: no new deficits.

A (ASSESSMENT)
1. AWV completed — preventive care up to date except items below.
2. Updated problem list: HTN (controlled), hyperlipidemia (stable).
3. Risk factors identified: diet, sedentary periods.
4. Screenings due: colorectal screening interval approaching;
   immunizations to update per schedule.

P (PLAN — Personalized Prevention Plan)
- Screening schedule provided to patient in writing.
- Order/arrange colorectal screening; update indicated immunizations.
- Counsel on diet and activity; reinforce continued tobacco abstinence.
- Continue current chronic-disease meds; routine labs per existing plan.
- Referrals: none today; dietitian offered.
- Patient given printed personalized prevention plan and follow-up timing.
- Advance care planning discussed; proxy documentation to be filed.

Tools like Doctor Notes can draft this AWV structure from the visit conversation, so the HRA review, screening list, and prevention plan land in the right SOAP sections while you stay face-to-face with the patient.

How is an AWV documented if a problem comes up during the visit?

It is common for a patient to raise an active issue during an AWV. The cleanest approach is to keep the preventive AWV documentation distinct, then document the additional problem-focused work as its own assessment and plan within the same encounter.

• Keep the AWV elements complete on their own.
• Document the separately identifiable problem with its own history, exam, and plan.
• Make the medical necessity of the extra work clear in the note.

FAQ

Is a physical exam required for a Medicare Annual Wellness Visit?

No comprehensive head-to-toe exam is required. The AWV centers on measurements like height, weight, BMI, and blood pressure plus standardized screens. Any focused exam beyond that is at your clinical discretion and may indicate separately documented work.

Can the SOAP format really be used for a preventive visit?

Yes. Map the HRA and history to Subjective, measurements and screens to Objective, the risk-stratified problem list to Assessment, and the written personalized prevention plan to Plan. The format stays familiar while capturing every required AWV element.

What is the most commonly missed AWV element in documentation?

The written, personalized prevention plan and the screening schedule are the items most often left implicit. Make sure the note states that a written plan was created and given to the patient, since that deliverable is central to the AWV.