A well-woman annual exam template gives you a repeatable structure for documenting the preventive gynecologic visit: interval history, gynecologic history, screening status, exam findings, counseling, and coding, in the order the visit actually runs. The best templates treat screening as a table with a next-due date for each test, because screening intervals now differ by test rather than by visit.

Below you'll find a free, downloadable well-woman exam template, a breakdown of every section, a worked screening-table example, the 2026 cervical cancer screening change that outdated most existing templates, and the Medicare coding rules that get this visit billed wrong.

Quick download: Grab the free Well-Woman Annual Exam template PDF here.

Key Takeaways

• The "annual" is no longer one visit, one set of tests: Cervical screening runs on a 3- or 5-year cycle, mammography on a 1- or 2-year cycle, bone density and colorectal screening on their own clocks. A good template records each screen with a next-due date instead of assuming everything happens yearly.
  
  

• The 2026 ACOG change outdated most templates: For ages 30–65, clinician-collected primary hrHPV testing every 5 years is now the preferred screening method, replacing the old "three equivalent options" framing. Templates built before 2026 quietly document to superseded guidance.
  
  

• Medicare bills this visit differently than commercial payers: G0101 covers the screening pelvic and clinical breast exam, and Q0091 covers obtaining the Pap specimen: every 24 months at average risk, every 12 months at high risk. Getting the pairing wrong is one of the most common preventive-visit denials.
  
  

• A structured template protects the counseling half of the visit: Contraception, menopause, IPV screening, and immunizations are where documentation thins out at the end of a busy encounter. Prompted fields, or an AI scribe that drafts the note for you, keep the second half of the note as complete as the first.
  
  

What Is a Well-Woman Annual Exam?

A well-woman annual exam is a preventive visit focused on gynecologic and reproductive health, age-appropriate screening, immunizations, and counseling. Unlike a problem visit, its purpose isn't to work up a complaint; it's to confirm the patient is current on every recommended screen, catch risk factors early, and address contraception, menstrual, menopausal, and sexual health concerns in one encounter.

The visit goes by several names depending on the setting: annual gynecologic exam, well-woman visit, annual preventive exam, or simply "the annual." The structure is the same, and it's covered without cost sharing as a preventive service under most plans.

One point worth documenting clearly: the visit is annual, but most of the tests are not. That distinction is exactly what a modern template needs to capture.

What to Include in a Well-Woman Exam Template

After the same sections show up in every high-quality well-woman note, a template earns its keep by prompting for all of them. Our free template is organized around seven:

• Interval history: Changes since the last visit: new diagnoses, hospitalizations, surgeries, medication changes, and any current concerns the patient wants addressed.
  
  

• Gynecologic history: Menstrual history (LMP, cycle pattern, abnormal bleeding), obstetric history (G/P, complications), sexual history, contraception method and satisfaction, and menopausal status and symptoms.
  
  

• Medical, family & social history: Chronic conditions, family history of breast, ovarian, colon, and endometrial cancer, tobacco/alcohol/substance use, and intimate partner violence screening.
  
  

• Screening table: One row per screen (cervical cancer, breast cancer, STIs, colorectal cancer, lipids/diabetes, bone density, depression) with four columns: the screen, the test actually performed, date and result, and when it's next due.
  
  

• Examination: Vitals and BMI, plus breast and pelvic exam findings when performed, with a note when an exam component is deferred and why.
  
  

• Counseling & immunizations: Contraception, preconception or menopause counseling as appropriate, lifestyle topics, and vaccines given or due (HPV, Tdap, flu, zoster by age).
  
  

• Assessment & plan with coding: Preventive visit code, screening codes, orders placed, referrals, and the follow-up interval.
  
  

The screening table is the heart of the template. A blank "Pap: done" line invites exactly the kind of note that fails an audit or misses a due date. A row that forces you to record which test, when, what it showed, and when it's next due stays accurate even as guidelines move.

Pro tip: Record the test performed, not just the category. "Cervical cancer screening: done" is ambiguous in 2026. "Primary hrHPV, clinician-collected, 03/2026, negative, next due 03/2031" is a complete data point that the next clinician, and the patient's recall system, can act on.

The 2026 Cervical Cancer Screening Change

Cervical cancer screening changed in 2026, and it's the single biggest reason to retire an older template. ACOG's Committee Statement No. 28 now recommends:

Two implementation notes matter for documentation:

• Self-collection is now an option. Patient-collected primary hrHPV testing every 3 years may be considered for ages 30–65 when systems exist for notification and follow-up. If your template can't distinguish clinician-collected from patient-collected, it can't document this pathway.
  
  

• "Preferred" replaced "three equivalent options." Any template that still presents cytology, co-testing, and hrHPV as interchangeable for the 30–65 band is presenting 2021 guidance. Documenting the test and next-due date, rather than relying on a memorized interval, is what keeps a note correct as guidance continues to move.
  
  

For patients who've had a hysterectomy with removal of the cervix and no history of cervical cancer or high-grade precancerous lesions, routine screening isn't recommended, and that's worth a line in the note, because "no Pap needed" without the reason invites a repeat conversation every year.

Worked Example: The Screening Table Filled In

Here's what a completed screening table looks like for a 42-year-old patient at average risk. (All details are fictitious.)

Notice what this table does that a checkbox list can't: it shows the patient is current on everything even though only two tests happened in the last year, it flags the colorectal start date before it's missed, and it gives next year's visit a ready-made worklist.

How to Document a Well-Woman Exam: Step by Step

A template gives you the skeleton. These five habits turn it into a note that holds up clinically and on audit.

1. Anchor the visit with the interval history

Start with what's changed since last year: new medications, new diagnoses, new symptoms the patient has been sitting on. This is also where problem-oriented concerns surface, which matters for coding later (see step 5).

2. Complete every row of the screening table

Even the rows where nothing was done. "Not indicated" with a reason is a documented clinical decision; a blank row is a gap. This is also where family-history updates change the plan; a new first-degree breast cancer diagnosis can move mammography timing and trigger a genetics conversation.

3. Document what was examined, and what was deferred

Pelvic exams are no longer automatic at every annual for asymptomatic patients; when one is performed or deferred, note the shared decision. Same for the clinical breast exam. "Deferred after discussion, patient asymptomatic, screening current" is a defensible line; silence is not.

4. Give counseling its own section, not a throwaway line

Contraception method and satisfaction, menopause symptoms and options, IPV screening result, immunizations given or declined. These topics are the reason the visit exists for many patients, and they're the first thing to vanish when notes are written from memory at the end of clinic. If your gynecologic history-taking needs structure, a dedicated HPI template helps here too.

5. Code the preventive visit, and split out problems honestly

The preventive codes (99383–99387 new, 99393–99397 established) cover the well-woman visit for commercial payers. If a significant problem was also addressed, a problem E/M with modifier 25 may be appropriate, but only when the work is genuinely separate and separately documented.

Bottom line: The well-woman note is a status dashboard, not a narrative. Complete rows, explicit next-due dates, and documented decisions beat paragraphs every time.

Medicare Coding: Where This Visit Gets Billed Wrong

Medicare doesn't pay the preventive medicine codes for the well-woman exam. Instead, it covers two specific screening services:

• G0101: screening pelvic examination and clinical breast exam

• Q0091: obtaining, preparing, and conveying the screening Pap specimen to the lab

Both are covered every 24 months at average risk and every 12 months for high-risk patients. Three mistakes account for most denials:

• Billing annually for average-risk patients. The 24-month clock runs from the last covered service, not the calendar year.
  
  

• Billing Q0091 when collection is already part of a preventive visit. Q0091 is not separately billable when specimen collection is bundled into a preventive encounter being billed another way.
  
  

• Missing the high-risk documentation. The 12-month interval requires the qualifying risk factor to be documented; the shorter interval isn't automatic.
  
  

An AI medical coder that checks interval eligibility and code pairing at the point of documentation catches these before the claim goes out rather than in the denial queue.

Common Well-Woman Documentation Mistakes to Avoid

• Treating every screen as annual. Fix: a next-due column per test, so the note reflects each test's actual cycle.
  
  

• "Pap done" without the test type. Fix: record cytology vs. primary hrHPV vs. co-testing, and clinician- vs. patient-collected.
  
  

• Undocumented deferred exams. Fix: one line noting the shared decision and that screening is current.
  
  

• Counseling compressed to "discussed contraception." Fix: method, satisfaction, changes made, and follow-up plan.
  
  

• Copy-forwarding last year's screening table. Fix: update every row with this year's dates; a stale next-due date is worse than a blank one, because it looks current.
  
  

Hands-Free Well-Woman Notes with Sully.ai

A template solves the structure problem. It doesn't solve the timing problem: well-woman visits pack history, exam, counseling, and orders into a short slot, and the note usually gets written after the patient leaves, exactly when the counseling details fade.

This is where an AI medical scribe changes the workflow. With Sully.ai, the ambient scribe captures the encounter and drafts the note in your well-woman template (screening table, counseling section, next-due dates) ready for review before the next patient. The AI medical coder then validates the preventive and screening codes, including the Medicare interval rules above.

Sully.ai is built for healthcare from the ground up and meets HIPAA standards for handling protected health information. Browse the full template library for related documentation, or see the blog for more guides.

Frequently Asked Questions

What is included in a well-woman annual exam?

A well-woman exam includes interval and gynecologic history, medical and family history review, age-appropriate screening (cervical cancer, breast cancer, STIs, and others by age and risk), a physical exam as indicated, immunizations, and counseling on contraception, menopause, and lifestyle. The visit confirms the patient is current on every recommended screen, even those not due this year.

Do I still need a Pap smear every year?

No. Under 2026 ACOG guidance, patients aged 21–29 need cytology every 3 years, and patients aged 30–65 should have clinician-collected primary hrHPV testing every 5 years as the preferred method. The annual visit still happens yearly; the cervical screening test does not.

What changed in the 2026 cervical cancer screening guidelines?

ACOG's 2026 statement made clinician-collected primary hrHPV testing every 5 years the preferred screening method for ages 30–65, replacing the previous framing of three equivalent options. It also introduced patient-collected hrHPV testing every 3 years as an option when follow-up systems are in place.

How is a well-woman exam billed?

For commercial payers, use preventive medicine codes 99383–99387 (new patients) or 99393–99397 (established) by age. For Medicare, bill G0101 for the screening pelvic and breast exam and Q0091 for Pap specimen collection: every 24 months at average risk, every 12 months at documented high risk.

Is a pelvic exam required at every well-woman visit?

No. For asymptomatic patients, the pelvic exam is a shared decision between clinician and patient rather than an automatic annual component. Whichever way the decision goes, document it: the choice, the reasoning, and that screening remains current.

When should a patient stop cervical cancer screening?

After age 65, patients at average risk with adequate prior negative screening and no history of high-grade lesions can stop. Patients who have had a hysterectomy with cervix removal, and no history of cervical cancer or high-grade precancerous lesions, don't need routine screening; document the reason so it isn't relitigated every year.

This template is provided for documentation reference only. Adapt it to your specialty, payer requirements, and current screening guidelines. It does not replace clinical judgment.

This article is for general informational purposes and is not legal, billing, or medical advice. Confirm that any form you use meets applicable regulations, including HIPAA, and consult your compliance team before deploying it.