Wiki Social History components

[vjtiwari99]

Hi,

Can we consider relations mentioned under HPI or MDM as social history viz., discussed with Grand-daughter, grand childerns etc.,

"Because the patient's workup was unremarkable for a 92-year-old ago the patient to go home and followup with primary care physician. She states she has a gallbladder scan coming up on Thursday. The granddaughter and great-granddaughter were advised of the findings. Patient is advised he may return to the emergency room for any further problems. Written instructions were given. Patient was cautioned and advised regarding diagnosis, treatment, results and plan and voiced an understanding.

So can we consider this as Social Hx. Would appriciate your help!!!

P.S.-

Social history (SH) ?
An age appropriate review of past and current activities
Marital status and/or living arrangements
Current employment, Occupational history
Military History
Use of drugs, alcohol, and tobacco
Sexual history
Level of education
Other relevant social factors


VJ

 

[kak6]

I would say no that is not enough for social history, the fact pt has a Granddaughter, will not be sufficient. Now if it stated "Pt currently lives with Granddaughter who also cares for pt" ... needs to be more of a history element to to use that one.

 

[vjtiwari99]

Hey, thanks for your opinion...

However, I think, if patient is 92 yrs old, he directed to go to home & follow up with primary care & the granddaughter and great-granddaughter were advised of the findings.

These statements itself reflecting that patient has a family members who are also available with him during this visit, so we can use this as "Living arrangements or Other relevant social factors".

Please suggest.

VJ