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Family Medicine Specialist Template

Medicare Well Visit (test)

A professional Family Medicine Specialist template for healthcare professionals.
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Specialty

Family Medicine Specialist

Used

42 times

Type

Note

Last edited

22/5/2025

Created by

Victoria Dantchenko

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About this template

The Medicare Well Visit template is designed for family medicine specialists to document comprehensive annual check-ups for patients covered by Medicare. This template facilitates the recording of a patient's active medical problems, social history, and home safety assessments. It also includes sections for screening tools, oral health, and advance directives, ensuring a thorough evaluation of the patient's overall health and well-being. By using this template, clinicians can efficiently capture all necessary information during a Medicare Well Visit, promoting preventive care and early detection of potential health issues.

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John Doe is a 67-year-old male patient with a PMH listed below presents to complete their Medicare Well Visit today, for routine check-up, and preventive services. Patient Active Problem List: - Hypertension - Type 2 Diabetes - Hyperlipidemia Social History Tobacco Use Non-smoker No smokeless tobacco usage Visit Type: Medicare Well Visit Demographics verified Social Connection and Isolation Screening: No issues reported Patient Care Team: - Dr. Sarah Johnson, Cardiologist - Dr. Emily White, Endocrinologist Patient's self-rated health status: Good Recent hospital discharge information: None Date of Discharge: N/A Recent emergency room or urgent care visit information: None Date of Visit: N/A Significant previous hospital stays, injuries, or treatment information: None Home Safety: Tub or shower safety assessment: Safe Tub or shower safety counseling: Not applicable Toilet support assessment: Safe Toilet support counseling: Not applicable Rug safety assessment: Safe Rug safety counseling: Not applicable Floor clutter assessment: Safe Floor clutter counseling: Not applicable Fall history information: No falls reported Morse Fall Risk Score: 0 Get-up-and-go-test: Normal Detailed observations of patient's ability to rise from a chair: No issues observed Oral health: Dentist visit information: Last visit 6 months ago Dentures present: Upper denture information: None Lower denture information: None Screening Tools: Depression screening status and result: Negative ADL & IADL screening status and result: No deficiencies ADL or IADL deficiencies not linked to physical limitations assessment: None Confusion or memory loss assessment: No issues reported MINI-COG completion status: Completed, normal Advance Directive: Health Care Proxy: Assigned to spouse, Jane Doe Medication reconciliation status: Completed, no discrepancies

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