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In medicine, a social history (abbreviated "SocHx") [1] is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.
For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".
Some notes include a "reason for consultation", which is similar but may address a physical finding from a physician as opposed to a symptom from a patient. history of present illness (HPI) "Pt is a 30 yo female (with a PMH of x and y) presenting with a 3 hour history of abdominal pain..." Including a separate paragraph summarizing related history.
The physician will take a history of present illness, or HPI, of the CC. [1] This describes the patient's current condition in narrative form, from the time of initial sign/symptom to the present. [10] It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded. [1]
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Chief complaints (CC) - what made patients seek medical attention. History of present illness (HPI) - circumstances relating to chief complaints. Past medical history (PMHx) Past surgical history; Current medications; Allergies; Family history (FHx) Social history (SocHx) Physical examination (PE) Laboratory results (Lab)