Social History Section¶

Template ID: 2.16.840.1.113883.10.20.22.2.17 Version: R2.1 (2015-08-01) Badge: Core Section

Overview¶

The Social History Section documents social and behavioral factors that influence a patient's physical, psychological, or emotional health. This includes smoking status, alcohol use, drug use, occupation, living situation, and other social determinants of health. This implementation focuses primarily on smoking status as required by Meaningful Use.

Clinical Purpose and Context¶

The Social History Section records: - Smoking status (required by Meaningful Use) - Alcohol and substance use - Occupation and occupational hazards - Living situation and social support - Sexual history and practices - Education level - Religious and cultural practices - Pregnancy status

This information is essential for: - Comprehensive patient assessment - Risk stratification and prevention - Treatment planning and counseling - Meeting Meaningful Use Stage 2 requirements - Addressing social determinants of health - Population health management

When to Include¶

The Social History Section is commonly included in: - Continuity of Care Documents (CCD) - History and Physical Notes - Consultation Notes - Annual wellness visits - Preventive care visits

Smoking status is required by Meaningful Use Stage 2 and must be documented for eligible patients.

Template Details¶

Official OID¶

Root: 2.16.840.1.113883.10.20.22.2.17
Extension: 2015-08-01 (V3)

Conformance Level¶

Conformance: SHOULD (Recommended; SHALL for Meaningful Use compliance)
Section Code: 29762-2 (LOINC - "Social History")

Cardinality¶

Section: 0..1 (Optional but highly recommended)
Entries: 0..* (At least one Smoking Status observation is required for Meaningful Use)

Smoking Status - Meaningful Use (V2): 2.16.840.1.113883.10.20.22.4.78:2014-06-09
Social History Observation (V3): 2.16.840.1.113883.10.20.22.4.38:2015-08-01
Pregnancy Observation: 2.16.840.1.113883.10.20.15.3.8
Tobacco Use (V2): 2.16.840.1.113883.10.20.22.4.85:2014-06-09

Protocol Requirements¶

The SmokingStatusProtocol defines the data contract for smoking status observations (the primary social history observation type). Each smoking status observation must provide:

Required Properties¶

Property	Type	Description
`smoking_status`	`str`	Description of smoking status
`code`	`str`	SNOMED CT code from Smoking Status Value Set
`date`	`date` or `datetime`	Date when smoking status was observed

Data Types and Constraints¶

smoking_status: Human-readable status (e.g., "Current every day smoker", "Former smoker", "Never smoker")
code: SNOMED CT code from value set 2.16.840.1.113883.11.20.9.38
date: Point-in-time observation (not an interval)

Common Smoking Status Codes¶

Code	Display Name
449868002	Current every day smoker
428041000124106	Current some day smoker
8517006	Former smoker
266919005	Never smoker
266927001	Unknown if ever smoked
77176002	Smoker, current status unknown
428071000124103	Current Heavy tobacco smoker
428061000124105	Current Light tobacco smoker

Code Example¶

Here's a complete working example using ccdakit to create a Social History Section:

from datetime import date, datetime
from ccdakit.builders.sections.social_history import SocialHistorySection
from ccdakit.core.base import CDAVersion

# Define a smoking status using a simple class that implements SmokingStatusProtocol
class SmokingStatus:
    def __init__(self, smoking_status, code, date):
        self.smoking_status = smoking_status
        self.code = code
        self.date = date

# Create smoking status instance
smoking_statuses = [
    SmokingStatus(
        smoking_status="Former smoker",
        code="8517006",
        date=date(2023, 10, 18)
    )
]

# Build the Social History Section
section_builder = SocialHistorySection(
    smoking_statuses=smoking_statuses,
    title="Social History",
    version=CDAVersion.R2_1
)

# Generate XML element
section_element = section_builder.build()

# Convert to XML string (for demonstration)
from lxml import etree
xml_string = etree.tostring(section_element, pretty_print=True, encoding='unicode')
print(xml_string)

Example with Multiple Observations¶

from datetime import date
from ccdakit.builders.sections.social_history import SocialHistorySection
from ccdakit.core.base import CDAVersion

class SmokingStatus:
    def __init__(self, smoking_status, code, date):
        self.smoking_status = smoking_status
        self.code = code
        self.date = date

# Track smoking status over time
smoking_statuses = [
    # Current status (most recent)
    SmokingStatus(
        smoking_status="Former smoker",
        code="8517006",
        date=date(2023, 10, 18)
    ),
    # Historical status for reference
    SmokingStatus(
        smoking_status="Current every day smoker",
        code="449868002",
        date=date(2020, 1, 15)
    )
]

section_builder = SocialHistorySection(
    smoking_statuses=smoking_statuses,
    title="Social History",
    version=CDAVersion.R2_1
)

section_element = section_builder.build()

Official Reference¶

For complete specification details, refer to the official HL7 C-CDA R2.1 documentation: - HL7 C-CDA R2.1 Implementation Guide - Section: 5.56 - Social History Section

Additional resources: - Meaningful Use Stage 2 Requirements - SNOMED CT Smoking Status Value Set

Best Practices¶

Common Patterns¶

Always Document Smoking Status
Required for Meaningful Use Stage 2
Update at each visit or annually
Use most current status
Document as point-in-time observation, not historical interval
Use Correct SNOMED CT Codes
Use codes from the Smoking Status Value Set
Most common: "Never smoker" (266919005), "Former smoker" (8517006), "Current every day smoker" (449868002)
Don't use codes outside the value set
Unknown status: use "Unknown if ever smoked" (266927001)
Document Current Status
Smoking status represents current status at the time of observation
Not a historical summary
Update when status changes
Most recent observation is considered current
Include Date of Observation
Document when status was assessed
Important for determining currency of information
Use encounter date or assessment date
Can use datetime for precision
Consider Additional Social History
While smoking is required, consider documenting:
- Alcohol use
- Substance use
- Occupation
- Living situation
- Sexual activity
Use appropriate observation templates for each

Validation Tips¶

Section Code Validation
Ensure section code is 29762-2 (LOINC "Social History")
This is automatically set by the builder
Template ID Validation
Verify template ID includes extension="2015-08-01"
Smoking Status observation uses different template: 2.16.840.1.113883.10.20.22.4.78:2014-06-09
Code Validation
Verify smoking status codes are from the approved value set
Value Set OID: 2.16.840.1.113883.11.20.9.38
Use VSAC (Value Set Authority Center) for validation
Observation Code Validation
Smoking status observations use code 72166-2 (LOINC "Tobacco smoking status NHIS")
This is the required observation code for Meaningful Use
Value Element Validation
The smoking status code goes in the value element, not the code element
value element uses SNOMED CT codes
code element uses LOINC code 72166-2

Gotchas to Avoid¶

Code vs. Value Confusion
observation/code = 72166-2 (LOINC - what is being observed)
observation/value = SNOMED CT code (the observed status)
Don't put the smoking status code in the code element
Using Wrong Value Set
Must use codes from Smoking Status Value Set (2.16.840.1.113883.11.20.9.38)
Don't use generic tobacco use codes
Don't create custom codes
Missing Smoking Status
Meaningful Use requires smoking status for eligible patients
Don't omit section entirely
If unknown, use "Unknown if ever smoked" (266927001)
Required for patients 13 years and older
Incorrect Date Interpretation
Date is when status was observed, not when smoking started/stopped
Don't use date patient quit smoking
Use date of clinical encounter or assessment
Historical vs. Current Status
Document current status, not smoking history
"Former smoker" is a current status
Don't create multiple entries unless status changed
Most recent observation is considered current
Status Changes
When status changes, create new observation
Both observations can be included for context
Most recent date indicates current status
Pediatric Patients
Meaningful Use applies to patients 13 years and older
Consider age-appropriate codes
"Never smoker" is common for adolescents
Document even if status seems obvious
Pregnancy Status Confusion
Pregnancy is documented separately
Uses different observation template
Don't confuse with smoking status
Both can be in Social History section
Text Description Mismatch
Ensure smoking_status text matches the code
Builder uses provided text in narrative
Should be consistent with SNOMED CT display name
Empty Social History Section
- While section is optional, smoking status is required for MU
- Include section even if only documenting smoking status
- Don't rely on other sections for smoking documentation
Substance Use Documentation
- If documenting substance use, use appropriate templates
- Tobacco Use observation (2.16.840.1.113883.10.20.22.4.85) for details
- Smoking Status observation for MU requirement
- Different templates serve different purposes
Narrative-Entry Consistency
- Ensure narrative matches structured data
- Builder handles this automatically
- Include status and date in narrative
- Important for human readability
Multiple Social History Types
- Section can contain multiple observation types
- Each type uses its own template
- Current builder implementation focuses on smoking status
- Extensible for additional social history observations
Point in Time vs. Interval
- Smoking status is point in time (effectiveTime with single value)
- Not a time interval (no low/high)
- Represents status at observation date
- Different from habits documented over time
Quality Reporting
- Smoking status used in many quality measures
- Currency matters (within last 24 months typically)
- Accurate coding essential for quality reporting
- Impacts meaningful use attestation