Social History Documentation and Review for Clinical Staff

Introduction

Social History is required to be reviewed at every patient visit. This includes documenting, at a minimum, tobacco status for meaningful use and Home/Environment information for rural health clinics. Follow practice guidelines for additional Social History documentation.

Social History Documentation and Review

Access Social History from the Histories workflow page component, Histories on the left side menu, or from an Intake PowerForm.

Documenting New Social History

1. Click [Add].
2. If a patient or family is unable to provide social history information, select Unable to Obtain.
3. The Add History dialog box is displayed with a list of questions specific to each category.
4. Complete the required categories and any additional categories as directed by your practice.

The 'Add History' dialog box shows fields for 'Category' (e.g., Tobacco), 'Details', 'Last Updated', and 'Last Updated By'. It includes buttons like '+ Add', 'Modify', and a 'Display: Active' filter. A table entry shows 'Smoking Status: 4 or less cigarettes' and 'Tobacco Type: Cigarettes'. The 'Unable to Obtain' checkbox is also visible.

Note: The red script in the Social History section serves as a guide to support effective questioning and encourage patient responses to Sexual Orientation and Gender Identity (SOGI) questions.

Reviewing Previously Documented Social History

1. Highlight the desired Social History Category and click the Modify button or right-click on the Category and select Modify.
2. If an error message is displayed:
   • Right-click on the Category and select Add History.
   • Then right-click on the outdated documentation and select Remove History.
3. Click OK.

Documenting Sexual Orientation and Gender Identity Information

The following questions are now required fields for each patient 18 years and older. (Recommendations pending for those under 18.)

1. Select the patient's self-described sexual orientation.
2. Select the patient's self-identified gender identity. This is a multi-select field. If "Addl gender category..." is chosen, a comment field will appear, allowing entry of the patient's specific description.

• Within the Inpatient setting, CMS requires that this data be collected once during the admission process.
• Within the Ambulatory setting, CMS requires this data be collected one time per 365-day period.

The 'Sexual' section includes options for 'Self described orientation' with choices like 'Straight or heterosexual', 'Lesbian or gay', 'Bisexual', 'Don't know', and 'Choose not to disclose'. The 'What is your current gender identity?' section is a multi-select field with options such as 'Identifies as male', 'Identifies as female', 'Female-to-Male (FTM)/Transgender Male/Trans...', 'Male-to-Female (MTF)/Transgender Female/Tr...', 'Genderqueer, neither exclusively male nor female', 'Addl gender category or other, please specify', and 'Choose not to disclose'.

Note: Sexual History can be reviewed and edited within the Provider Workflow Histories component.

Abuse/Neglect Screening

The Abuse/Neglect category of Social History contains 5 mandatory fields for patients 18 and older and 1 mandatory field for pediatric patients. Documentation to meet regulatory guidelines is required once every 365 days for all patients.

1. Screen the patient and document the patient's response to each question.
2. Selecting Unable to respond for ANY Abuse/Neglect question will create a Task that must be documented on by clinical staff. Refer to the steps below on documenting the Task.
3. Document whether clinical evidence of Abuse/Neglect Risk is present. Pediatric screenings will contain this question only.

The Abuse/Neglect screening questions include 'Has anyone tried to harm you in any way?', 'Feels unsafe at home:', 'Do you fear a partner or other person?'. Response options include 'Yes', 'No', and 'Unable to respond'. A 'Comment' field is also present.

When abuse or neglect is reported, notify the provider, and provide resources to the patient. Options for resources may include:

• Referral to care management.
• Referral to behavioral health.
• Domestic violence resources.
• Shelter resources .
• Referral to Adult Protective Services (APS)/Child Protective Services (CPS), Phone 855-444-3911.

Completing Abuse/Neglect Screening Tasks

If Unable to Respond was selected as an answer for ANY Abuse/Neglect question, the Abuse/Neglect Screening Task should be completed:

1. Navigate to the patient Task List from the PowerChart Menu.
2. To open the task documentation, double-click the task or right-click and choose Chart Details.
3. Select the Reason why the patient was unable to respond. Select Other to free text a reason.
4. Click the green check mark ✔️ to complete and sign the PowerForm.

The process involves navigating to the 'Task List' within PowerChart. A task titled 'Complete Abuse/Neglect Screening Task' is shown, with an instruction to 'Double Click to document'. The 'Abuse/Neglect Screening' form for 'Reason why patient was unable to respond' includes options like 'Altered mental status/confused', 'Cognitively impaired', 'Family/caregiver present', 'Intubated', 'Prefer not to answer', 'Speech impaired', 'Unresponsive', and 'Other', along with a 'Comments' field. A green checkmark button is used to finalize.

Note: If the task does not display on either Task List, personal settings may need to be corrected. Refer to the Clinical Personalization document on the Clinical EHR Education website for instructions.