What is included in a complete social history during a history and Mental Status Examination (MSE)?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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Answer

Obtain a complete social history of the patient. Ask patients their marital status. Also, inquire about employment status. If the patient is employed, inquire about the frequency of absences from work. If the patient is not employed, inquire about whether the patient currently is looking for work. Also inquire if a previously held job was lost as a result of the illness. Obtain as much detailed information as possible.

Recording an accurate educational history is imperative. Inquire how far the patient went in school. Ask if he or she was in special education classes. Ask if the patient has a learning disability and if the patient has any other problem such as a hearing impairment or speech problem. These issues are very important in the evaluation of patients undergoing psychiatric assessment, and patient care could be jeopardized if they are not addressed. A patient's communication problems, for example, could be due to a language disorder rather than a thought disorder, and the initiation of psychiatric medications could further affect communication, not to mention cause legal concerns for the prescribing physician. All of these things must be kept in mind at all times when completing the social history.

Record the number, sex, and age of the patient's children. Ask if any of the children have any medical or psychiatric problems. List the patient's toxic habits, including past and current use of tobacco, alcohol, and street drugs. This is important because many patients can become dependent on prescribed medications. Try to determine whether the patient has a history of drug abuse.

Include any military history, including length of service and rank. This could help determine if a patient is eligible for US Veterans Administration benefits or other assistance.

Another important issue in obtaining a very thorough patient history is the patient's housing status. This becomes a vital part of the discharge plans. Ask if the patient has a home. Inquire if they have a family and if they have contact with that family. Ask where the patient will go at the completion of his or her hospital stay. Also ask who will ensure that the patient remains compliant with medication therapy. These become crucial points when finding placement for patients at discharge and planning long-term follow-up care. Therefore, careful recording of housing and support is very important.

Inquire about the existence (and number) of siblings, their names and phone numbers, and any church affiliations, just in case the information is needed later.

Also in the history section, record any legal problems the patient may have had in the past. This should include jail time, probation, arrests (eg, for driving while intoxicated or driving under the influence of drugs), and any other relevant information that can provide insight into the patient's problems with the law.

Patient history also should include hobbies, social activities, and friends. If the patient has any history of abuse, mental or physical, it should be recorded here. Any other relevant information that may be useful in treating the patient or helpful in aiding in aftercare should be recorded in the patient history.

Inquire about the patient's and the patient's parents' religious beliefs. Did the patient grow up in a strict religious environment? Does the patient have a particular religious belief and has that changed since childhood, adolescence, or adulthood? Investigate what effect the patient's beliefs have on treatment of psychiatric illnesses or suicide.


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