Social history (medicine)

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
  • Firearms in household (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
gollark: Or is just very good at memorizing things by looking at them.
gollark: But whatever.
gollark: Well, I guess it's more general than that.
gollark: It's a room where they put tools for students to use.
gollark: I see.

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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