3.7 Social History

The template identifier for the social history section is 2.16.840.1.113883.10.20.1.15.

This section contains data defining the patient’s occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation. Social history can have significant influence on a patient’s physical, psychological and emotional health and wellbeing so should be considered in the development of a complete record.

CONF-232: CCDSHOULD contain exactly one and SHALL NOT contain more than one Social history section (templateId 2.16.840.1.113883.10.20.1.15). The Social history section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more social history observations (templateId 2.16.840.1.113883.10.20.1.33).

3.7.1 Section conformance

CONF-233: The social history section SHALL contain Section / code.
CONF-234: The value for “Section / code” SHALL be “29762-2” “Social history” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-235: The social history section SHALL contain Section / title.
CONF-236: Section / titleSHOULD be valued with a case-insensitive language-insensitive text string containing “social history”.

3.7.2 Clinical statement conformance

The following figure shows a subset of the CDA Clinical Statement model containing those classes being constrained or referred to in the conformance statements that follow.

Figure 9. CDA R2 model for social history

3.7.2.1 Social history observation

The template identifier for a social history observation is 2.16.840.1.113883.10.20.1.33.

CONF-237: A social history observation (templateId 2.16.840.1.113883.10.20.1.33) SHALL be represented with Observation.
CONF-238: The value for “Observation / @classCode” in a social history observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-239: The value for “Observation / @moodCode” in a social history observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-240: A social history observation SHALL contain at least one Observation / id.
CONF-241: A social history observation SHALL include exactly one Observation / statusCode.
CONF-242: The value for “Observation / statusCode” in a social history observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.
CONF-243: The value for “Observation / code” in a social history observation SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), or MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.18 SocialHistoryTypeCode STATIC 20061017.
CONF-244: Observation / value can be any datatype. Where Observation / value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression.
CONF-245: A social history observation SHALL contain one or more sources of information, as defined in section 5.2 Source.

3.7.2.2 Representation of “status” values

The template identifier for a social history status observation is 2.16.840.1.113883.10.20.1.56.

CONF-246: A social history observation MAY contain exactly one social history status observation.
CONF-247: A social history status observation (templateId 2.16.840.1.113883.10.20.1.56) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values).
CONF-248: The value for “Observation / value” in a social history status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.17 SocialHistoryStatusCode STATIC 20061017.

3.7.2.3 Episode observations

The template identifier for an episode observation is 2.16.840.1.113883.10.20.1.41.

The representation of episode in the social history section is the same as the representation in the problems section. See section 3.5.2.3 Episode observations for details.

CONF-249: A social history observation MAY contain exactly one episode observation (templateId 2.16.840.1.113883.10.20.1.41) (see section 3.5.2.3 Episode observations).

3.7.2.4 Social history observations vs. CDA Header attributes

The ASTM CCR includes “administrative data (ADT) such as marital status, ethnicity, nationality, and religious preferences” in the Social History section. CDA R2 differentiates between administrative data and clinical observations, supporting the former in the CDA Header and the latter in the CDA Body. As a result, it is necessary at times to populate attributes in the CDA Header, and to provide richer clinical details in the CDA Body.

CONF-250: Marital status SHOULD be represented as ClinicalDocument / recordTarget / patientRole / patient / maritalStatusCode. Additional information MAY be represented as social history observations.
CONF-251: Religious affiliation SHOULD be represented as ClinicalDocument / recordTarget / patientRole / patient / religiousAffiliationCode. Additional information MAY be represented as social history observations.
CONF-252: A patient’s race SHOULD be represented as ClinicalDocument / recordTarget / patientRole / patient / raceCode. Additional information MAY be represented as social history observations.
CONF-253: The value for “ClinicalDocument / recordTarget / patientRole / patient / raceCode” MAY be selected from codeSystem 2.16.840.1.113883.5.104 (Race).
CONF-254: A patient’s ethnicity SHOULD be represented as ClinicalDocument / recordTarget / patientRole / patient / ethnicGroupCode. Additional information MAY be represented as social history observations.
CONF-255: The value for “ClinicalDocument / recordTarget / patientRole / patient / ethnicGroupCode” MAY be selected from codeSystem 2.16.840.1.113883.5.50 (Ethnicity).