A checklist or another method of documentation indicating that the seven elements of the initial preventive physical exam have been addressed must be maintained in the patient record. The encounter form has been designed to do that.
In addition, you are required to give your patient a written plan for obtaining the appropriate preventive services. I suggest that you make a copy of the form’s second page to give to the patient at the exam’s conclusion. If you want to get fancy, you could design a similar form with a duplicate page two, allowing you to keep the original and give the carbon copy to the patient.
This form has been updated since its original publication date to reflect changes to Medicare's covered services. You can download the updated encounter form as a PDF here.
Over time, you will become more adept at completing the initial preventive physical exam in a reasonable period. CMS considers the physician/non-physician provider time component of the initial preventive physical exam to be equivalent to a 30-minute 99203 (new patient, level-three E/M code).
To speed the process along, you could use preprinted patient education materials to counsel your patient. For some specific examples available on Familydoctor.org, AAFP’s patient education Web site, see “Preprinted handouts.” It would also be helpful to ask your patients to bring to the visit the “Guide to Medicare’s Preventive Services,” which each new beneficiary is receiving in their Welcome to Medicare package. It can be viewed or downloaded at https://www.medicare.gov/Pubs/pdf/10110.pdf.
Familydoctor.org has patient education materials regarding many of the preventive health issues covered in an initial preventive physical exam.
Breast cancer screening