Medicine:Social history

From HandWiki

In medicine, a social history (abbreviated "SocHx")[1] is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.

Components

Components can include inquiries about:

  • Substances
  • occupation
  • sexual behavior (increased risk of various infections among prostitutes, people who have sex with people for money, and males engaging in anal-receptive intercourse)
  • prison (especially if tuberculosis needs to be ruled out)
  • travel
  • exercise
  • diet
  • Firearms in household (especially if children or persons with cognitive impairment are present)

Relation to history

CMS required history elements[2]
Type of history CC HPI ROS Past, family, and/or social
Problem focused Required Brief N/A N/A
Expanded problem focused Required Brief Problem pertinent N/A
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete

References