Wiki Questions on AWV documentation


Local Chapter Officer
Best answers
Our practice is new to doing AWVs and I want to make sure we are documenting all the requirements appropriately. I've been reviewing the CMS document for AWVs:, and I have a couple of questions.

The required elements list ADLs and IADLs under both the Administer HRA and Review functional ability and safety check boxes. Do the ADLs and IADs need to be documented twice in the progress note, or as long as they are clearly documented once, is that sufficient to meet both of these required elements?

Do you use the social history field to support psychosocial and behavioral risks? What do you consider psychosocial risks? (I have providers asking me this question...).

If there are no findings on a hearing assessment, fall risk, cognitive assessment, home safety, must you note that it was reviewed with no findings, or can you just omit? (I know the answer, but need input to support my argument with the providers).

Do your patients actually receive the personalized health advice on paper to take with them when they leave the appointment, or is the provider documenting it in the note sufficient?

Thanks for your experienced input!!! Much appreciated!