November 24th, 2015
By: Codapedia Editor (Jul/27/2015)
The Documentation Guidelines say social history is:
an age appropriate review of past and current activities.
As auditors, we interpret this to include:
- smoking, alcohol and drug use
- living arrangements
- employment history
- school history
- support system, if relevant
In order to credit social history in a note, any one of those must be reviewed. There is no requirement that all of them are reviewed. There is no description in the guidelines of how extensive the social history must be. Most auditors count it if one of the above are present.