Confidential Social History

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Confidential Social History

Contents 1. Definition of Social History 2. Social History components 3. CMS and Payor requirements 4. Population Health Data 5. Issues with confidentiality as related to the Personal Heath Record (Patient Portal) and adolescent medicine

1. Definition of Social History Social History is a required component of documentation of a patient chart in an Electronic Medical Record (EMR). The patient’s chart documents their chronological history and is essential to providing quality care and establishing a secure physician-patient relationship.

Social history paints an entire picture of the patient outside of their medical history encompassing lifestyle, risks of illness or injuries, and what make the patient unique. It is designed to be gathered once, modified as necessary and populate the patient’s chart on each visit encounter to give the clinician a place to store this information for reference. The Social History can be as brief as tobacco history or as complex as all of the example questions below.

As part of the EHR, the gathering of the social history should prompt the clinician with the types of questions to ask, and allow both rapid check boxes and free text descriptors. The use of the check boxes allows comprehensive gathering of data for reporting in population health studies. It must be flexible and adaptable for adults, women, children, adolescents and gender equality. 2. Social History Components

a. Tobacco History i. Amount ii. Type (including smokeless tobacco/vaping) iii. Packs/Day iv. Number of Years v. Total Pack Years vi. Last Use vii. Tobacco used last 365 days* viii. Exposure to tobacco smoke ix. Started at (age) x. Stopped at (age) xi. Ready to change xii. Previous treatment

b. Alcohol Use History i. Use (None, current, past, other) ii. Type iii. Frequency iv. Amount v. Number of Years vi. Last Use

c. Substance Use History i. Drug Use (none, current, past, other) ii. Type iii. Route iv. Frequency v. Number of Years vi. Amount vii. Last Use

d. Sexual History i. Current gender identity 1. Identifies as male 2. Identifies as female 3. Female-to-male/Transgender Male/Trans Man 4. Male-to Female/Transgender Female/Trans Woman 5. Genderqueer, neither exclusively male nor female 6. Additional genderqueer category 7. Choose not to disclose 8. Other ii. Do you think of your sexual orientation as: 1. Lesbian, gay or homosexual 2. Straight or heterosexual 3. Bisexual 4. Something else 5. Don’t know 6. Choose not to disclose 7. Other iii. Sexually Active? iv. First active at age___ v. Current partners vi. Number of lifetime partners vii. Are your partners 1. Ambiguous 2. Both 3. Female 4. Male 5. Indeterminate 6. Unknown 7. Other viii. Uses condoms Y/N ix. Other contraceptive use x. History of sexual abuse xi. Other sexual concerns

e. Employment/School i. Status: 1. Employed 2. Part time 3. Retired 4. Student 5. Unemployed 6. Other ii. Description iii. Previous employment/schools iv. Activity level 1. Desk/Office 2. Occasional Physical Work 3. Moderate Physical Work 4. Heavy Physical Work v. Highest Education 1. None 2. High School 3. Some College 4. University degree(s) 5. Post graduate degree(s) 6. Other vi. Hazardous Equipment Operation Y/N vii. Work Hazards 1. Hazardous Materials 2. Heavy lifting/twisting 3. Loud noises 4. Medical/Clinical work 5. Repetitive motion 6. Shift/Night work 7. Vibration viii. School Concerns 1. Learning 2. Social 3. Communication 4. Health 5. Cultural ix. Other

f. Exercise i. Duration (average number of minutes) ii. Times per week: 1. 1-2 times/week 2. 3-4 times/week 3. 5-6 times a week 4. Daily iii. Physical Activity Intensity 1. Light 2. Moderate 3. Vigorous 4. Other iv. Physical Activity Consultation 1. Counseled to start physical activity 2. Counseled to maintain physical activity 3. Counseled to modify physical activity v. Exercise type: 1. Walking 2. Aerobics 3. Running 4. Swimming 5. Weight Lifting 6. Yoga vi. Screen time hours per day vii. Sleep number hours per night viii. Education about screen time given Y/N ix. Self assessment 1. Poor condition 2. Fair condition 3. Good condition 4. Excellent condition g. Home Environment i. Lives with: 1. Alone 2. Children 3. Father 4. Mother 5. Siblings 6. Significant Other 7. Spouse ii. Marital Status 1. Married 2. Unmarried 3. Divorced 4. Separated 5. Other iii. Spouse Name iv. Guardian Information v. Marital Status if patient is a dependent minor vi. Sibling Information vii. Home Equipment 1. CPAP/BiPAP 2. Feeding Tube 3. Glucose Monitoring 4. IV therapy 5. Monitoring 6. Oxygen 7. Respiratory Treatments 8. Special bed 9. Ventilator 10. Walker/Cane 11. Wheelchair viii. Special Services and Community Resources 1. Adult Protective Services 2. Child Protective Services 3. Clergy 4. Counseling 5. Court Order 6. Discharge transportation 7. Gifted program 8. Housekeeping 9. Meal delivery/preparation 10. Restraining order 11. Schooling 12. Special Education 13. Support group 14. WIC 15. Other ix. Family/Friends available to help x. Concern for family members at home xi. Major illness in household xii. Financial concerns xiii. Religious restrictions/concerns 1. Blood products 2. Dietary restrictions 3. Same gender caregiver xiv. Other risks in environment 1. Unlocked guns 2. Does not use seat belts 3. Does not wear helmet 4. Hazardous chemicals/paint 5. High risk sports 6. Pets/Animal exposure 7. Pool/Lake 8. Smoke/CO2 detectors absent 9. No others declared xv. Pet in Household xvi. Alcohol abuse in household xvii. Substance abuse in household xviii. Smoker in household xix. Injuries/Abuse/Neglect in household xx. Feels unsafe at home? xxi. Safe place to go? xxii. Agency/Others notified

h. Nutrition/Health i. Diet description ii. Type of diet 1. Regular 2. Calorie restricted 3. Diabetic 4. Vegetarian 5. Other iii. Caffeine intake amount iv. Diet restrictions v. Vitamins/Supplements vi. Wants to lose weight? vii. Sleeping concerns viii. Feels highly stressed ix. Uses alternative healthcare

3. CMS and Payor Requirements a. Center for Medicare Services (CMS) requires certain components of history to code and bill different levels of charging and determining medical necessity. Documentation must be complete in every category to qualify, therefore a complete social history carries equal importance as a complete physical examination. i. There are four basic types of coding levels, Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. Each one of these levels has different requirements in gathering information from the categories of the patient note, Chief Complaint, History of Present Illness, Review of Systems, Past, Family or Social History, and Type of History. ii. The lower two levels do not require elements from the Past, Family or Social History. The Detailed level requires a pertinent review of Past, Family or Social History, and the Comprehensive level requires a complete review of the Past, Family or Social History. iii. Gathering the Social History Data not only allows storage of pertinent information about the patient but satisfies the billing and coding requirements. iv. Each coding level requires documentation of a review of the record or updating previously gathered information. v. Services documented for coding must meet medical necessity requirements outlined by the Health Insurance Portability and Accountability Act, utilizing ICD-!0 and CPT code terminology in order to qualify for payment. Social History components are required as part of this code. vi. Documentation of coordination of care can be the majority of time spent caring for a patient in the acute or ambulatory setting. Utilizing data obtained through a comprehensive social history review can effectively provide the information needed to coordinate care for the patient and satisfy the billing requirements for Family and Social History.

4. Population Health Data a. Population Health studies utilizes required reported information to synthesize data regarding the study of certain human populations. b. Review and study of the social history component of population health improves recommended preventative health, promoting health equity, studies of incidence of use of tobacco, substance abuse, and gender studies, review of education, housing and employment statistics. c. Governments utilize this reportable population health data to determine health care spending and in development of support programs. d. Patients are more likely to provide sensitive information to their trusted health care provider than an unknown government data collector. e. Difficult to reach patients may be able to provide more accurate data to their health care provider than a government data collector.

5. Issues with confidentiality as related to the Personal Heath Record (Patient Portal) and adolescent medicine a. Adults over 18 should control the accessibility and viewing of their own PHR b. Adolescents over 12 should have the ability to control who accesses their confidential social history c. Children under 12 should expect their parent or guardian to determine accessibility and viewing of their confidential social history d. Adolescents should have the assurance that their confidential history will not be viewable in the patient portal. This may require programming of types of social history information gathering and storage systems that are excluded from the patient portal by their health care provider. e. When an Electronic Health Record is shared throughout a health system incorporation acute and ambulatory care, placing sensitive information in a shared social history widget may put the physician-patient relationship at risk. This is especially true in the pediatrician-adolescent relationship where protection confidential information is of utmost importance. An easily adoptable solution is to use a separate documentation form built for confidential social history that can be excluded from viewing in the patient portal. This is not infallible, however, as other outside users still may place information in the social history widget despite the best efforts of the primary pediatrician. It is important that adolescents fully understand the information made available in the patient portal and have the option to opt out thoroughly explained.


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Submitted by (Gina Sulmeyer)