Social history (medicine)

From Wikipedia, the free encyclopedia

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, johns, and males engaging in anal-receptive intercourse)
  • prison (especially if tuberculosis needs to be ruled out)
  • travel
  • exercise
  • diet
  • (especially if children or mentally handicapped persons 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[]

  1. ^ "Medscape.com". Archived from the original on January 1, 2004. Retrieved 2009-04-10.
  2. ^ "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original (PDF) on 2012-04-11. Retrieved 2011-02-27.
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