Little more than tobacco, ethanol, and drugs: Internal medicine residents??? documentation of social histories on an inpatient medicine unit

Abstract

Emily Kobin, Elizabeth Chow, Randy S. Hebert

Objective: Social environments play an important role in patient health. Some educators, however, have recently commented that the social history has been minimized by graduate resident physicians to the documentation of tobacco, ethanol, and drug (TED) use. To the best of our knowledge, last time, this subject was formally explored approximately 20 years ago. We therefore investigated the social histories of inpatient admission notes written by internal medicine residents at one institution from July 2014 through June 2015. Methods: We reviewed 153 and 103 admission notes by interns and senior internal medicine residents, respectively. Notes were compared to investigate whether the social history would differ by year of training. Results: The majority of notes contained information about patients’ TED use, i.e. in 91.1%, 91.8%, 77.2% of intern and 94.2%, 93.2%, and 84.5% of senior residents’ social histories. Other documented topics included housing environment (48.1% vs. 79.6%), marital status or children (29.7% vs. 44.7%), and occupation (28.5% vs. 35.0%). Senior residents were more likely to record housing environment and marital status or children than that of interns. Other social history topics were recorded very little if at all. Conclusions: Despite the important role social environments play in patients’ health, interns and residents recorded very little of the social history other than TED in their admission notes. We believe that further investigation is warranted into why residents poorly document social histories and whether the lack of information affects patient care.