How to Document Social History of a Patient in EMR

Documenting the social history of a patient in the EHR provides a comprehensive view of the patient’s background and lifestyle factors. Follow these steps to ensure accurate and thorough documentation:

Steps to Document Social History of a Patient in EMR:

Step 1: Access the Patient Tab

From the main dashboard, click on “Patient Tab”.

Step 2: In the Patients Tab:

Search and select the patient’s name.

Step 3: Open the Consults Section

Select “Consults” and then click “View” to access the patient's record.

Step 4: Navigate to Diagnosis Info

Click on “Diagnosis Info” to open the patient’s medical information.

Step 5: Select Social History (SH)

Choose “SH” to document the social history of the patient.

Step 6: Populate the Template

From the dropdown menu, select the appropriate option for the patient’s social history.
Click on the green Play button to populate the documentation template.

Step 7: Complete the Social History Details

Fill in the following sections as applicable:
- Childhood
- Personal Status
- Socioeconomic Status
- Highest Education Completed
- Places Visited
- Places Lived
- Diet
- Exercise
- Home Conditions
- Occupation
- Environment
- Domestic Violence
- Support System
- Military Record
- Religious or Cultural Preferences
- Access to Care
- Smoking History
- Alcohol Use
- Illicit Drugs
- Sexual History
- Breast Self-Exams
- Stress

Step 8: Generate the Completed Template

Click “Generate” to create the final documentation.

Step 9: Save the Social History

Click “Save” to record the social history of the patient in the EHR.

By following these steps, you ensure that the patient’s social history is documented accurately, supporting better care planning and a holistic understanding of the patient’s background.