“Any alcohol use? Any tobacco use? Any other drugs?”
These are the three main questions that most health care providers ask their patients when documenting a social history on a note.
“What stressors do you have in your life? What social support do you have? What is your home life like? What do you do for fun? Do you wear a helmet when you ride a bike? Do you wear a seatbelt?”
I remember learning these questions and having to ask them to a standardized patient as a medical student. My classmates and I laughed about how silly some of these questions seemed. How does wearing a helmet have anything to do with my patient’s pneumonia? Why do I care about what my patient does for fun when they’re having a medical emergency?
A recent patient encounter I had showed me that sometimes a more thorough social history can help me to better understand my patient. I had a patient who I was admitting from the emergency department with a chief complaint of shortness of breath and chest pain. I only had a few minutes to review her prior notes before seeing her. There was one thing I noticed in the social history, however, that helped me better understand my patient. This was not only mentioned in her primary care provider’s notes, but in the various subspecialty physician notes as well.
“The patient is the primary caregiver to her husband, who has dementia.”
This statement primed my brain. As I reviewed the patient’s medications with her, she told me she had not been taking several of her prescribed medications over the past week. From reviewing her prior notes, this seemed a bit unusual as she typically was very compliant with her medications. As I asked her some more questions, I learned that her husband had just passed away. She had been busy being a caregiver to her husband, and also had to deal with the funeral preparations. Even after her husband’s death, my patient had an amazing caregiver mentality:
“I’m just glad all of this happened now and not when everything had been going on over the past couple of weeks.”
My patient recovered and was discharged home to her very supportive family. I felt confident that she would have proper follow-up and social support, as her family had been in the hospital with her and was very involved in her care. At the end of her hospitalization, it was amazing to see how much stronger she was than when she first came in.
The social history was very helpful in this situation and can be applied to almost any patient. Social factors can be a major hindrance for patients to be healthy. In this example, my patient had excellent social support from her family. Despite even the best support, caregivers still get overwhelmed and can put their loved one’s health needs in front of their own. It’s important to tell our patients who are caregivers that they need to be extra cognizant about taking care of themselves. An ill caregiver is not going to be as helpful as a well caregiver.
Taking this a step further, it is even more overwhelming for caregivers if they do not have social support. If they are the only ones caring for their loved one, it can be an extremely daunting task. Perhaps one of the most unavoidable social history issues is financial stress. Caregivers may try to save money by not going to see their own doctor. They may avoid taking their medications or refilling their own prescriptions to save money.
Health care providers don’t have time to ask all the social history questions with every patient. The social history, however, provides us with a small window into the lives of our patients. Our patients are more than their diseases. It’s easy for providers (myself included) to get frustrated when people don’t listen to our recommendations. By looking at the big picture, we can better understand the daily lives of our patients. If our patients feel that their health care providers are trying to better understand their day to day lives, they may be more inclined to work as a team with their providers to ensure they live as healthy lives as possible.
David Goldberg is an internal medicine intern who blogs at Help Me End Alzheimer’s.
Image credit:Shutterstock.com
September 15, 2016 Kevin 52
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September 15, 2016 Kevin 0
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FAQs
Social history is a broad category of the patient's medical history but may include the patients smoking or other tobacco use, alcohol and drug history and should also include other aspects of the patient's health including spiritual, mental, relationship status, occupation, hobbies, and sexual activity or pertinent ...
What is the purpose of social history? ›
Answer and Explanation: Social history is important because it studies the experiences of ordinary people in history. Studying ordinary people can provide a much more nuanced, insightful, and relatable perspective of historical events.
What is included in a patient's social history quizlet? ›
A section of the health history includes information on the patient's lifestyle, such as health habits, and living environment. The social history is important because the patient's lifestyle may have an impact on his or her condition and may influence the course of treatment by the physician.
Why do doctors ask about social history? ›
Along with the chance to connect with the patient as a person, the social history can provide vital early clues to the presence of disease, guide physical exam and test-ordering strategies, and facilitate the provision of cost-effective, evidence-based care.
Why is a patients social history important? ›
Each lives in a greater social and community context outside of healthcare and their “life story” – the social history – is a critical part of their care. It allows us both to build rapport and to understand the challenges our patients face and the strengths they bring to their experience of illness.
What is an example of social history? ›
History topics considered social history:
Urban History, Suburban History, Rural History. History of gender (how masculinity, femininity, other gender identities were expressed/socially constructed and enforced) History of racial and ethnic categories. History of Children/Childhood, Adolescence, Aging.
What is the difference between social history and cultural history? ›
Answer and Explanation:
Social history is the study of societal structures, social change, and individual experiences, whereas cultural history is the study of everyday life, experiences, values, and norms attached to cultural production.
What questions do you ask for social history? ›
Environmental / Social Questions
- What other health care professionals are currently helping care for you?
- What are your average daily activities?
- Any children? ...
- Ethnic background?
- Finances; home situation (location, suitability, help available, transportation)
- What do you do for a living?
- Any inherited diseases?
A client history , also known as a social history, is the relevant background information of a client's life that will be helpful in determining what courses of action need to be taken in providing therapy for the client.
What is not a part of a patients social history? ›
The correct answer is How many times the patient's spouse consumes alcohol per week. This is because a patient's social history typically focuses on their own personal habits and characteristics such as smoking, relationship status, and occupation.
A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests.
What are the types of information found in a patient's health record social history? ›
Social History, including marriage status, occupation, family situation, education, and habits, e.g., smoking status, alcohol consumption, diet, exercise, and sexual history.
What are the strengths of social history? ›
Undoubtedly one of the strengths of social history today is the encouragement it has given to, and the response by specialists in such fields as the history of law and its enforcement, of medicine and its practice, of industry, commerce, shipping and seamanship, vernacular architecture, domestic furnishings, costume, ...
Why is the medical history of a patient important? ›
Obtaining a medical history can reveal the relevant chronic illnesses and other prior disease states for which the patient may not be under treatment but may have had lasting effects on the patient's health. The medical history may also direct differential diagnoses.
What is the personal history of a patient? ›
A personal history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams, tests, and screenings. It may also include information about medicines taken and health habits, such as diet and exercise.
What does social history mean in an assessment? ›
In medicine, a social history (abbreviated "SocHx") 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.
What are two items that are part of a patient's social history? ›
However, it is a much richer section in the medical interview that includes a patient's birthplace, education, occupation, functional status, diet, sleep, tobacco, alcohol, illicit drug use, sexual history, and religion, which may be important factors related to the current illness.
How do you ask a patient about their social history? ›
Environmental / Social Questions
- What other health care professionals are currently helping care for you?
- What are your average daily activities?
- Any children? ...
- Ethnic background?
- Finances; home situation (location, suitability, help available, transportation)
- What do you do for a living?
- Any inherited diseases?
The correct answer is How many times the patient's spouse consumes alcohol per week. This is because a patient's social history typically focuses on their own personal habits and characteristics such as smoking, relationship status, and occupation.
