What it means
A section of the admission or history-and-physical note. It covers who the person lives with, their job, tobacco, alcohol and drug use, diet and activity, sexual history, travel and the help they have at home. These facts shape risks and discharge planning.
For the nurse
Ask social history questions privately and without judgment, and record the client's own words for substance use amounts.
At a glance
| Also written | social history |
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