How to write a social history of a patient

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How to write a social history of a patient

The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures. It is an important reference document that gives concise information about a patient's history and exam findings at the time of admission.

This information should be presented in a logical fashion that prominently features all data immediately relevant to the patient's condition. It is a means of communicating information to all providers who are involved in the care of a particular patient.

It allows students and house staff an opportunity to demonstrate their ability to accumulate historical and examination based information, make use of their medical fund of knowledge, and derive a logical plan of attack. It is an important medical-legal document.

An instrument designed to torture Medical Students and Interns. Meant to cover unrelated bits of historical information. Should neither require the killing of more then one tree nor the use of more then one pen to write!

Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology.

If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history.

Until you gain experience, your write-ups will be somewhat poorly focused. Not to worry; this will change with time and exposure. Several sample student write-ups can be found at the end of this section. One sentence that covers the dominant reason s for hospitalization. Smith is a 70 year old male admitted for evaluation of increasing chest pain.

The HPI should provide enough information without being too inclusive. Traditionally, this covers all events leading to the patient's arrival in the ER or the floor, if admission was arranged without an ER visit.

Events that occurred after arrival are covered in a separate summary paragraph that follows the pre-hospital history. Some HPIs are rather straight forward. If, for example, you are describing the course of an otherwise healthy 20 year old who presents with 3 days of cough, fever, and shortness of breath, you can focus on that time frame alone.

It gets a bit more tricky when writing up patients with pre-existing illness es or a chronic, relapsing problem. In such cases, it is important to give relevant past history "up front," as having an awareness of this data will provide contextual information that will allow the reader to better understand the most recent complaint.

If, for example, a patient with a long history of coronary artery disease presents with chest pain and shortness of breath, it might be written as follows: S is a 70 yr old male with known coronary artery disease who is: This represented a significant change in his anginal pattern, which is normally characterized as mild discomfort which occurs after walking vigorously for 8 or 9 blocks.

In addition, 1 day prior to admission, the pain briefly occurred while the patient was reading a book. He has also noted swelling in his legs over this same time period and has awakened several times in the middle of the night, gasping for breath.

In order to breathe comfortably at night, Mr. S now requires the use of 3 pillows, whereas in the past he was always able to lie flat on his back without difficulty.

how to write a social history of a patient

S is known to have poorly controlled diabetes and hypertension. He denies fevers, chills, cough, wheezing, nausea vomiting or other complaints. However, it is obviously of great importance to include all of the past cardiac information "up front" so that the reader can accurately interpret the patient's new symptom complex.

From a purely mechanical standpoint, note that historical information can be presented as a list in the case of Mr. S, this refers to his cardiac catheterizations and other related data.

This format is easy to read and makes bytes of chronological information readily apparent to your audience. While this data is technically part of the patient's "Past Medical History," it would be inappropriate to not feature this prominently in the HPI.

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Without this knowledge, the reader would be significantly handicapped in their ability to understand the patient's current condition. Knowing which past medical events are relevant to their area of current concern takes experience. In order to gain insight into what to include in the HPI, continually ask yourself, "If I was reading this, what historical information would I like to know?

The remainder of the HPI is dedicated to the further description of the presenting complaint. As the story teller you are expected to put your own spin on the write-up.

how to write a social history of a patient

That is, the history is written with some bias. You will be directing the reader towards what you feel is the likely diagnosis by virtue of the way in which you tell the tale.Social History Assessment [Arlene B. Andrews] on vetconnexx.com *FREE* shipping on qualifying offers.

Her book takes us on a journey back to the basics of conducting a thorough and informative social history and is an account of what a real social history involves I recommend this book not only for the novice but also for all clinicians who want an edge on how to accumulate more pertinent.

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Social history (medicine) - Wikipedia