Comprehensive Error Rate Testing Annual Wellness Visit Health Risk Assessment Checklist

Health Risk Assessment (HRA) performed. Patient self-reported information obtained. (You or the patient can update the HRA before or during the AWV.)

At a minimum, collect this information:

• Demographic data
• Health status self-assessment
• Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, and fatigue
• Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
• Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances

Patient’s medical and family history established.

At a minimum, document:

• Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
• Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
• Use of, or exposure to, medications, supplements, and other substances the person may be using

• Document current patient providers and suppliers that regularly provide medical care, including behavioral health care

• Height, weight, body mass index (or waist circumference, if appropriate), and blood pressure
• Other routine measurements deemed appropriate based on medical and family history

• Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others
• Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementias Resources for Professionals has more information.

Patient’s potential depression risk factors reviewed.

Depression risk factors include:

• Current or past experiences with depression
• Other mood disorders

Patient’s functional ability and level of safety reviewed.

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

• Ability to perform ADLs
• Fall risk
• Hearing impairment
• Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment (LCD L39266).

An appropriate patient written screening schedule established.

Base the written screening schedule on the:

• Checklist for the next 5–10 years
• U.S. Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
• Patient’s HRA, health status and screening history, and age-appropriate preventive services Medicare cover

Patient’s list of risk factors and conditions established.

Include:

• A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
• Mental health conditions, including depression, substance use disorders, and cognitive impairments
• Initial Preventive Physical Examination (IPPE) risk factors or identified conditions
• Treatment options and associated risks and benefits

Personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs provided.

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:

• Fall prevention
• Nutrition
• Physical activity
• Tobacco-use cessation
• Social engagement
• Weight loss
• Cognition

Advance care planning (ACP) services at the patient’s discretion provided.

ACP is a discussion between you and the patient about:

• Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
• Future care decisions they might need or want to make
• How they can let others know about their care preferences
• Caregiver identification
• Advance directive elements, which may involve completing standard forms

Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning (PDF) fact sheet has more information.

Medicare doesn’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV (LCD L38970).

Current opioid prescriptions reviewed.

For a patient with a current opioid prescription:

• Review any potential opioid use disorder risk factors
• Evaluate their pain severity and current treatment plan
• Provide information about non-opioid treatment options
• Refer to a specialist, as appropriate

Potential substanse use disorders (SUDs) screening performed.

Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource (PDF).

Social Determinants of Health (SDOH) Risk Assessment

Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.

• Medical records, including immunization records
• Detailed family health history
• Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists