AWE Protocol & Checklist

📢 Patient Notification 

Inform Patient: Discuss that only services deemed ‘preventative’ by insurance are covered. Any additional labs, tests, or procedures not classified as preventative may result in out-of-pocket costs.

💊 Medication & Allergies

• Medication Reconciliation:
  • Review and update all active medications in Drchrono.
  • Add new medications, including OTC and supplements.
  • Remove non-active medications.
• Allergies:
  • Document all allergies.
  • If none, check “NKDA” (No Known Drug Allergies) and/or “no current medications” as appropriate.

♾️ Chronic Conditions 

List all chronic medical conditions and their current status (e.g., “Hypothyroidism, stable on levothyroxine 75mcg daily since 12/2020”).

📜 Medical History

Please ensure that the medical history matches the one we have in the EHR under the tab Medical History. In the case it does not, update it. 

• Last AWE: Document date of last Annual Wellness Exam.
• History of last blood work completed: Date and type of last labs.
• History of lab abnormalities: Note any significant past lab abnormalities.
• Medical Problems: List all known medical problems.
• Hospitalizations: List all, with year or age.
• ER Visits: List all, with year or age.
• Surgeries: List all, with year or age.
• Supplements/Herbs: List all current supplements and herbal products.

🧼 Preventative & Specialty Care

• Last dental exam: Date and findings.
• Last vision exam: Date and findings.
• Dermatology (Derm): Any history of skin issues, last skin check, or concerning lesions.

👪 Family History

Please ensure that the family history matches the one we have in the EHR under the tab Medical History. In the case it does not, update it. 

• Country of origin/ethnicity
• Parents: Age (do not write “A&W”); if deceased, age and cause of death; chronic conditions (HTN, DM2, HLD, etc).
• Siblings: Age and chronic medical conditions.
• Children (if applicable): Age and medical conditions (e.g., healthy, asthma).
• Other family history: Note significant negatives (e.g., “No FHx cardiovascular issues; MI/cancer/sudden death <50 y/o”).

💉 Vaccinations (Quality Metric)

• Review and document all immunizations.
• Use “show all” to ensure a complete review.
• Include recommended ages and provide links to guidelines as appropriate.

🤝 Social History

Please ensure that the social history matches the one we have in the EHR under the tab Medical History. In the case it does not, update it. 

• General: Place of origin, education level.
• Occupation: Specific role, company, stress level.
• Sexual History: Gender identity, sexual orientation.
• Relationship Status: Married, single, divorced, widowed, partner, etc.; new partner, monogamous, open?
• Exercise: Type, frequency, duration.
• Diet: Type (vegan, vegetarian, keto, etc.), servings of fruits/vegetables.
• Safety: Home safety (smoke/carbon monoxide detectors, seatbelts, etc.), personal safety.
• Caffeine: Daily intake.
• Alcohol: Type, amount, frequency.
• Tobacco (Quality Metric): PPD, duration, quit in last 15 years?
• Cannabis/Marijuana: Current use, frequency.
• Illicit Drugs: Type and frequency.

🧠 Mental and Behavioral Health

• Trouble sleeping: Assess for sleep quality, insomnia, or other sleep disturbances.
• Mindfulness/Mental Health: Screen for mood, anxiety, stress, coping skills, and mindfulness practices.
• Patients should complete the GAD-7 / PHQ-9. This can be found in their documents and can be completed directly through the app.

✅ Quality & Preventative

• Sexually Active (Quality Metric): Yes/No.
• STI Screening (Quality Metric): Last screened, if warranted.
• Colon Cancer: Document family history.
• Lipid Screening: Most recent date or “ordered on (date of visit)”.
• Diabetes Screening: Most recent date or “ordered on (date of visit)”.
• Next AWE Due Date: 12 months from current visit.
• Female Specific: 
  • Pap/Cervical History (Quality Metric): Last pap date, results, next due date; obtain previous Gyn info for records.
  • Contraception: Current use, type, date of implant.
  • Pregnancies: G’s and P’s (# pregnancies, deliveries, abortions/miscarriages).
  • Breast/Mammography: Family history, due date, past results.
  • Menstruation History: LMP, cycle length, irregularities.
• Male Specific: 
  • Prostate: Family history, due date, past results.
  • AAA: Family history, smoking history (duration).

🧼 Vital Signs

• BP: Last recorded (encourage at-home or pharmacy readings).
• HR: Last recorded (often from BP cuff).
• Height/Weight/BMI: Record; if not recent, use driver’s license/passport data.

⌨️ ICD-10 Coding for AWE and Preventive Screenings

• General AWE:
  • Z00.0 – General adult medical examination
  • Z00.01 – General adult medical examination with abnormal findings
• Screening Codes:
  • Z13.1 – Encounter for screening for diabetes mellitus
  • Z13.820 – Encounter for screening for lipoid disorders
  • Z11.3 – Encounter for screening for infections with a predominantly sexual mode of transmission
  • Z11.4 – Encounter for screening for human immunodeficiency virus (HIV)
  • Z11.59 – Encounter for screening for other viral diseases
  • Z13.22 – Encounter for screening for metabolic syndrome
  • Z12.31 – Encounter for screening mammogram for malignant neoplasm of breast (if ordering mammogram)

⚠️ Note: Do not include ICD-10 codes for conditions not addressed during the AWE.