Patient Social History Example. Example of a Complete History and Physical Write-up. Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart.
Do the full Mini-Mental State Examination if delirium, dementia, or other cognitive change is in the differential diagnosis.
Social history- he still lives alone with few supports and continues to smoke".
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This is the opportunity to find out a bit more about the patient's The above example involves the CVS so you would focus on the others. Despite even the best support, caregivers still get overwhelmed and can put their loved one's health needs in front of their own. The social history was very helpful in this situation and can be applied to almost any patient.
