Identifying social risk via a clinical social history embedded in the electronic health record

Although the link between social determinants and health outcomes is well established, the social history remains poorly integrated into clinical care processes. This study's purpose was to determine social risk documentation rates among newborns using a new electronic template. A retrospective review of 639 well-infant visits was performed. The authors determined documentation rates for a standardized social history embedded in the clinic electronic health record. Social history completion rates and prevalence of risks were identified. More than 80% of clinicians documented asking at least 1 of 7 questions (mean = 4.5, SD = 2.9). The most commonly asked question was about "making ends meet," and the least common was about personal safety (79% vs 57%, P .01). Nearly 30% of caregivers reported at least 1 risk, 11% at least 2 risks. An electronic health record-embedded social history led to documented screening in more than 80% of visits, identifying 30% as having at least 1 social risk.