Wiki Social History

[KaylaRieken]

Does this count when my providers say does not pertain to the patient? Usually the patient is a child. Our EMR social history usually pertains to alcohol history, smoking history, marital status, language, caffeinated beverages.

 

[cgaston]

I personally would give credit for it.

I would not give credit if they left it blank or typed "N/A" but since it states "does not pertain to the patient" I think that it shows they addressed these things but they do not apply to this particular patient.

 

[Pathos]

Depends on the context and the chart. And this can be a double edged sword to just "skip" over a question depending on the age or gender of the patient. Some kids do drink caffeinated beverages (energy drinks and coffee) and even smoke, and should perhaps not be easily dismissed by the provider, and some questions are truly not relevant to the patient (hopefully alcohol history and others). As a coder/auditor, I would probably accept such a statement, but this is again all part of the context.