How do I document social history?

Any practice member can document social history on the patient Summary and within an encounter. Social history is composed of smoking status, gender identity, and sexual orientation.

Document Social History on the Summary
1. Locate the Social history header or select the Go to... drop-down menu and choose Social history.

2. To document smoking status, click the + icon next to the corresponding section. Enter the current status and effective date, then click Save. If appropriate, you can document multiple smoking statuses to reflect changes in behavior over time.


3. To document gender identity, click the + icon next to the corresponding section. You must make a selection before you can enter a free-text note. Click Save when done.


4. To document sexual orientation, click the + icon next to the corresponding section. You must make a selection before you can enter a free-text note. Click Save when done.


5. To edit or remove an existing entry for smoking status, gender identity, or sexual orientation, click on the existing entry. Click Delete, then confirm that you would like to remove the entry from the patient’s record.


Document Social History in an Encounter
1. Open an existing encounter or start a new encounter.

2. Scroll through the encounter to locate the Social History section or use the Go to... tool at the top to quickly navigate to the section.

3. To document a new smoking status, gender identity, or sexual orientation entry, click Record next the corresponding header. Click on an existing entry to edit or delete it.

Charting

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  3. How do I complete a chart note?
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  9. How do I print a patient's chart or certain sections of the patient's chart?
  10. How do I print a chart note?
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  27. Where can I learn more about the different components of an encounter?
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  29. How do I edit information on the Patient Summary?
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  33. How do I change the date in an encounter?
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  35. How do I view more information for medications?
  36. Why am I receiving the error "Unable to sign" when trying to sign a chart note?
  37. How do I delete an unsigned encounter?
  38. Who can sign a chart note?
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  43. How do I edit an existing SOAP or Simple Note?
  44. How do I record "Unknown Family History?"
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  60. How do I add custom allergies?
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  64. How do I document social history?
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  66. Why am I seeing CCDA display errors?
  67. How do I manage display settings for inbound CCDAs?
  68. How do I add new Encounter Types?

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