Canadian Health Information Management Association Practice Exam

Documentation of drugs, alcohol, and tobacco use is part of which history?

1. History of present illness.

2. Medical history.

3. Social history.

4. Systems review.

The correct answer is: Social history.

The correct answer is social history because this aspect of patient documentation specifically focuses on the lifestyle and personal habits of the patient, which includes their use of drugs, alcohol, and tobacco. Social history helps healthcare providers understand the patient's behaviors and environmental factors that could affect their health status and treatment. While the history of present illness, medical history, and systems review all provide important clinical information, they primarily focus on other areas. The history of present illness details the current medical issues and symptoms. Medical history encompasses past illnesses, surgeries, and treatment histories. The systems review assesses the function of various body systems to uncover additional health issues. Therefore, the documentation of substances used is uniquely relevant to the social history, which sheds light on potential risks and influences on a patient's health.