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Interoperability Standards Advisory (ISA)
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    About the ISA


    • Structure
    • FAQs
    • Timeline and Comment Process
  • ISA Content

    ISA Content


    ISA Sections

    • Vocabulary/Code Set/Terminology
    • Content/Structure
    • Services/Exchange
    • Administrative

    Appendices

    • Sources of Security Standards and Security Patterns
    • Models and Profiles
    • Educational and Informational Resources
    • State and Local Public Health Readiness for Interoperability

    Specialty Care and Settings

    • COVID-19
    • Opioids
    • Pediatrics
    • Social Determinants of Health
  • ISA Publications

    ISA Publications


    • Web Version as Single Page
    • 2023 ISA Reference Edition
  • Recent ISA Updates

    Recent ISA Updates


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  • USCDI
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  • USCDI Data Classes - All Levels
    • Advance Directives
    • Allergies and Intolerances
    • Assessment and Plan of Treatment
    • Biologically Derived Product
    • Cancer Care
    • Care Team Member(s)
    • Clinical Notes
    • Clinical Tests
    • Diagnostic Imaging
    • Durable Medical Equipment (DME)
    • Encounter Information
    • Explanation of Benefit
    • Exposure/Contact Information
    • Facility Information
    • Family Health History
    • Functioning
    • Genomics
    • Goals
    • Health Concerns
    • Health Insurance Information
    • Health Status Assessments
    • Immunizations
    • Laboratory
    • Medical Device or Equipment
    • Medical Devices
    • Medications
    • Newborn's Delivery Information
    • Nutrition and Diet
    • Observations
    • Ophthalmic Data
    • Orders
    • Organization
    • Outcomes
    • Patient Demographics/Information
    • Patient Summary and Plan
    • Pregnancy Information
    • Problems
    • Procedures
    • Provenance
    • Recorded Sex or Gender Class
    • Referral
    • Research Data
    • Security Label
    • Sex For Clinical Use
    • Smoking Status
    • Social Determinants of Health
    • Social History
    • Special Alerts for Care Handoffs
    • Substance Use
    • Travel Information
    • Unique Device Identifier(s) for a Patient’s Implantable Device(s)
    • Vital Signs
    • Work Information

ISA Menu

  • Home
  • About the ISA
    • FAQs
    • Structure
    • Timeline and Comment Process
  • ISA Content
    • Administrative
      • Administrative Transactions - Non-Claims
        • Administrative Transaction Acknowledgements
        • Enrollment and Disenrollment in a Health Plan
        • Health Care Eligibility Benefit Inquiry and Response
        • Health Care Eligibility Benefit Inquiry and Response for Retail Pharmacy Coverage
      • Administrative Transactions to Financial Exchanges
        • Electronic Funds Transfer for Payments to Health Care Providers
        • Health Care Payment and Remittance Advice
        • Health Plan Premium Payments for Covered Members
      • Administrative Transactions to Support Clinical Care
        • Health Care Attachments to Support Claims, Referrals and Authorizations
        • Referral Certification and Authorization for Pharmacy Transactions
        • Referral Certification and Authorization Request and Response for Dental, Professional and Institutional Services
      • Health Care Claims and Coordination of Benefits
        • Health Care Claim Status Request and Response
        • Health Care Claims or Equivalent Encounter Information for Dental Claims
        • Health Care Claims or Equivalent Encounter Information for Institutional Claims
        • Health Care Claims or Equivalent Encounter Information for Professional Claims
        • Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Claims
        • Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Supplies and Professional Services
      • Operating Rules to Support Administrative Transactions
        • Attributed Patient Roster
        • Connectivity for Operating Rules
        • Operating Rules for Enrollment and Disenrollment
        • Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA)
        • Operating Rules for Health Care Claims
        • Operating Rules for Premium Payments
        • Operating Rules for Prior Authorization and Referrals
        • Operating Rules to Support Claim Status Transactions
        • Operating Rules to Support Electronic Prescribing Transactions
        • Operating Rules to Support Eligibility Transactions
    • Appendices
      • Appendix I – Sources of Security Standards and Security Patterns
      • Appendix II - Models and Profiles
      • Appendix III - Educational and Informational Resources
        • Understanding Emerging API-Based Standards
        • Understanding Observations and Observation Values
      • Appendix IV - State and Local Public Health Readiness for Interoperability
    • Content/Structure
      • Admission, Discharge and Transfer
        • Sending a Notification of a Long-Term Care Patient’s Admission, Discharge and/or Transfer Status to the Servicing Pharmacy
        • Sending a Notification of a Patient’s Admission, Discharge and/or Transfer Status to Other Providers
        • Sending a Notification of a Patient’s Encounter to a Record Locator Service
      • Care Coordination
        • Advanced Care Planning
        • Referral from Acute Care to a Skilled Nursing Facility
        • Referral to a Specialist - Request, Status Updates, Outcome
        • Referral to Extra-Clinical Services - Request, Updates, Outcome
      • Care Plan
        • Documenting and Sharing Care Plans for a Single Clinical Context
        • Documenting and Sharing Medication-Related Care Plans by Pharmacists
        • Documenting Care Plans for Person Centered Services
        • Domain or Disease-Specific Care Plan Standards
        • Sharing Patient Care Plans for Multiple Clinical Contexts
      • Clinical Decision Support
        • Communicate Appropriate Use Criteria with the Order and Charge to the Filling Provider and Billing System for Inclusion on Claims
        • Provide Access to Appropriate Use Criteria
        • Sharable Clinical Decision Support
      • Clinical Notes
        • Documentation of Clinical Notes
      • Clinical Quality Measurement and Reporting
        • Reporting Aggregate Quality Data for Quality Reporting Initiatives
        • Reporting Patient-level Quality Data for Quality Reporting Initiatives
        • Sharing Quality Measure Artifacts for Quality Reporting Initiatives
      • Data Provenance
        • Establishing the Authenticity, Reliability, and Trustworthiness of Content Between Trading Partners
      • Diet and Nutrition
        • Exchanging Diet and Nutrition Orders Across the Continuum of Care
      • Family Health History (Clinical Genomics)
        • Representing Family Health History for Clinical Genomics
      • Healthy Weight
        • Sending Healthy Weight Information
      • Human and Social Services
        • Format for Sharing Social Care Services Information
        • Format for Structuring and Sharing Social Care Directory Information
      • Images
        • Format of Medical Imaging Reports for Exchange and Distribution
        • Format of Radiation Exposure Dose Reports for Exchange and Distribution
        • Format of Radiology Reports for Exchange and Distribution
        • Medical Image Formats for Data Exchange and Distribution
      • Laboratory
        • Exchange InVitro Diagnostics (IVD) Orders and Results
        • Exchange Laboratory Test Results
        • Order Laboratory Test
        • Transmit Laboratory Directory of Services to Provider System
      • Medical Device Communication to Other Information Systems/Technologies
        • Transmitting Patient Vital Signs from Medical Devices to Other Information Systems/Technologies
      • Patient Education Materials
        • Clinical Information Systems to Request Context-Specific Clinical Knowledge From Online Resources
      • Patient Identity/Identification Management
        • Patient Demographic Record Matching
        • Representing Patient Address
        • Representing Patient Names
          • Representing Patient Names
      • Patient Preference/Consent
        • Recording Patient Preferences for Electronic Consent to Access and/or Share their Health Information with Other Care Providers
      • Pharmacy Interoperability
        • Allows Pharmacy Benefit Payers to Communicate Formulary and Benefit Information to Prescriber Systems
        • Allows a Long Term or Post-Acute Care to Request to Send an Additional Supply of Medication
        • Allows a Pharmacy to Notify a Prescriber of Prescription Fill Status
        • Allows a Pharmacy to Request Additional Refills
        • Allows a Pharmacy to Request a Change to a Prescription
        • Allows a Pharmacy to Request a New Prescription For a New Course of Therapy or to Continue Therapy
        • Allows a Pharmacy to Request, Respond to or Confirm a Prescription Transfer
        • Allows a Prescriber or a Pharmacy to Request a Patient’s Medication History
        • Allows a Prescriber to Cancel a Prescription
        • Allows a Prescriber to Communicate Drug Administration Events
        • Allows a Prescriber to Communicate with a REMS Administrator
        • Allows a Prescriber to Prescribe Medication Using Weight-Based Dosing
        • Allows a Prescriber to Recertify the Continued Administration of a Medication Order
        • Allows a Prescriber to Request a Patient’s Medication History from a State Prescription Drug Monitoring Program (PDMP)
        • Allows a Prescriber to Request, Cancel or Appeal Prior Authorization for Medications
        • Allows a Prescriber to Send a New Prescription to a Pharmacy
        • Allows a Prescriber to Send a Prescription to a Pharmacy for a Controlled Substance
        • Allows for Communication of Prescription Information Between Prescribers and Dispensers
        • Allows for the Exchange of State Prescription Drug Monitoring Program (PDMP) Data
      • Public Health Reporting
        • Adverse Event Reporting
        • Case Reporting to Public Health Agencies
        • Data Submission for Title X Family Planning Annual Reporting
        • Electronic Transmission of Reportable Laboratory Results to Public Health Agencies
        • Exchanging Immunization Data with Immunization Registries
        • Newborn Screening Results and Birth Defect Reporting to Public Health Agencies
        • Reporting Antimicrobial Use and Resistance Information to Public Health Agencies
        • Reporting Birth and Fetal Death to Public Health Agencies
        • Reporting Cancer Cases to Public Health Agencies
        • Reporting Death Records to Public Health Agencies
        • Reporting Syndromic Surveillance to Public Health (Emergency Department, Inpatient, and Urgent Care Settings)
        • Sending Health Care Survey Information to Public Health Agencies
      • Research
        • Data Collection for Submission to Registries and Reporting Authorities
        • Prepopulation of Research Forms from Electronic Health Records
        • Registering a Clinical Trial
        • Submission of Clinical Research Data Contained in EHRs and Other Health IT Systems for General Purpose or Preserving Specific FDA Requirements
        • Submission of Clinical Research Data to FDA to Support Product Marketing Applications
        • Submit Adverse Event Report from an Electronic Health Record to Drug Safety Regulators
      • Security Tags for Sensitive Information
        • Security Tags for Sensitive Information
      • Summary Care Record
        • Support a Transition of Care or Referral to Another Health Care Provider
      • Unique Device Identification
        • Defining a Globally Unique Device Identifier
        • Representing Unique Implantable Device Identifiers
        • Transmitting a Unique Device Identifier
      • Work Information
        • Work Information Templates
    • Services/Exchange
      • “Push” Exchange
        • An Unsolicited "Push" of Clinical Health Information to a Known Destination and Information System User
        • An Unsolicited “Push” of Clinical Health Information to a Known Destination Between Systems
        • Medical Device Communication to Other Information Systems/Technologies
        • Push Communication of Vital Signs from Medical Devices
        • Remote Patient Monitoring to Support Chronic Condition Management, Patient Education and Patient Engagement
        • Representing Path Traversal Expressions
      • Clinical Decision Support Services
        • Immunization Decision Support Forecast
        • Providing Patient-Specific Assessments and Recommendations Based on Patient Data for Clinical Decision Support
        • Retrieval of Contextually Relevant, Patient-Specific Knowledge Resources from Within Clinical Information Systems to Answer Clinical Questions Raised by Patients in the Course of Care
      • Consumer Access/Exchange of Health Information
        • Collection and Exchange of Patient-Reported Outcomes
        • Patient Exchanging Secure Messages with Care Providers
        • Push Patient-Generated Health Data into Integrated EHR
        • Remote Patient Authorization and Submission of EHR Data for Research
        • View, Download and Transmit Data from EHR
      • Healthcare Directory, Provider Directory
        • Listing of Providers for Access by Potential Exchange Partners
      • Image Exchange
        • Exchanging Images Outside a Specific Health Information Exchange Domain
        • Exchanging Images Within a Specific Health Information Exchange Domain
      • Infrastructure
        • Client Application Management
      • Patient Identity/Identification Management
        • Exchanging Patient Identification Within and Between Communities
      • Public Health Exchange
        • Transport for Immunization Submission and Query/Response
      • Publish and Subscribe
        • Publish and Subscribe Message Exchange
      • Query
        • Data Element Based Query for Clinical Health Information
        • Query for Documents Outside a Specific Health Information Exchange Domain
        • Query for Documents Within a Specific Health Information Exchange Domain
      • Resource Location
        • Care Service Discovery Within the U.S.
        • Finding and Retrieving Human Services Information
    • Specialty Care and Settings
      • COVID-19
      • Opioids
      • Pediatrics
      • Social Determinants of Health
    • Vocabulary/Code Set/Terminology
      • Allergies and Intolerances
        • Representing Patient Allergic Reactions
        • Representing Patient Allergies and Intolerances; Environmental Substances
        • Representing Patient Allergies and Intolerances; Food Substances
        • Representing Patient Allergies and Intolerances; Medications
      • Biologics
        • Representing Biological Products
      • Clinical Notes
        • Representing Clinical Notes
      • Clinical Tests
        • Representing Clinical Test Result/Value
        • Representing Non-Imaging and Non-Laboratory Clinical Tests
      • Cognitive Status
        • Representing Patient Cognitive Status
      • COVID-19 Novel Coronavirus Pandemic
        • COVID-19 Novel Coronavirus Pandemic
      • Demographics
        • Representing Patient Contact Information for Telecommunications
      • Dietary and Nutritional Needs
        • Representing Nutrition Assessment, Diagnosis, Interventions and Monitoring/Evaluation
      • Emergency Medical Services
        • Representing Health Care Data for Emergency Medical Services
      • Encounter Diagnosis, Assessment and Plan
        • Representing Assessment and Plan of Treatment
        • Representing Patient Dental Encounter Diagnosis
        • Representing Patient Medical Encounter Diagnosis
      • Family Health History
        • Representing Patient Family Health History
      • Functional Status/Disability
        • Representing Patient Functional Status and/or Disability
      • Goals
        • Representing Patient Goals
      • Health Care Providers, Family Members and Other Caregivers
        • Representing Health Care Providers
        • Representing Provider Role in Team Care Settings
        • Representing Relationship Between Patient and Another Person
      • Health Concerns
        • Representing Patient Health Concerns
      • Imaging (Diagnostics, Interventions and Procedures)
        • Representing Imaging Diagnostics, Interventions and Procedures
      • Immunizations
        • Representing Immunizations
      • Laboratory
        • Representing Laboratory Result Values
        • Representing Laboratory Test Ordered
        • Representing Laboratory Test Performed
        • Representing Laboratory Test Specimen
      • Medications
        • Representing Patient Medications
      • Nursing
        • Representing Clinical/Nursing Assessments
        • Representing Nursing Interventions
        • Representing Outcomes for Nursing
        • Representing Patient Problems for Nursing
      • Patient Clinical Problem List (i.e., "Conditions")
        • Representing Patient Clinical “Problems” (i.e., Conditions)
      • Preferred Language
        • Representing Patient Preferred Language (Presently)
      • Pregnancy Status
        • Representing Patient Pregnancy Status
      • Procedures
        • Representing Dental Procedures Performed
        • Representing Medical Procedures Performed
        • Representing Social Care Procedures
      • Provenance
        • Representing Data Provenance
      • Public Health Emergency Preparedness and Response
        • Representing Healthcare Personnel Status
        • Representing Hospital/Facility Beds Utilization
        • Representing Laboratory Operations (Population Laboratory Surveillance)
        • Representing Mass Vaccination Status
        • Representing Population-Level Morbidity and Mortality
      • Race, Ethnicity and Tribal Affiliation
        • Representing Patient Race and Ethnicity
        • Representing Tribal Affiliation
      • Research
        • Representing Data for Biomedical and Health Services Research Purposes
      • Sex at Birth, Sexual Orientation and Gender Identity
        • Representing Patient Gender Identity
        • Representing Patient Sex (At Birth)
        • Representing Patient-Identified Sexual Orientation
      • Social, Psychological and Behavioral Data
        • Representing Alcohol Use
        • Representing Depression
        • Representing Drug Use
        • Representing Exposure to Violence (Intimate Partner Violence)
        • Representing Financial Resource Strain
        • Representing Food Insecurity
        • Representing Housing Insecurity
        • Representing Level of Education
        • Representing Physical Activity
        • Representing Social Connection and Isolation
        • Representing Stress
        • Representing Transportation Insecurity
      • Tobacco Use
        • Representing Patient Electronic Cigarette Use (Vaping)
        • Representing Patient Secondhand Tobacco Smoke Exposure
        • Representing Patient Tobacco Use (Smoking Status)
      • Units of Measure
        • Representing Units of Measure (For Use with Numerical References and Values)
      • Vital Signs
        • Representing Patient Vital Signs
      • Work Information
        • Representing Job, Usual Work, and Other Work Information
  • ISA Publications
    • 2023 ISA Reference Edition
    • Web Version as Single Page
  • Recent ISA Updates
  • USCDI Data Classes - All Levels
    • Advance Directives
    • Allergies and Intolerances
    • Assessment and Plan of Treatment
    • Biologically Derived Product
    • Cancer Care
    • Care Team Member(s)
    • Clinical Notes
    • Clinical Tests
    • Diagnostic Imaging
    • Durable Medical Equipment (DME)
    • Encounter Information
    • Explanation of Benefit
    • Exposure/Contact Information
    • Facility Information
    • Family Health History
    • Functioning
    • Genomics
    • Goals
    • Health Concerns
    • Health Insurance Information
    • Health Status Assessments
    • Immunizations
    • Laboratory
    • Medical Device or Equipment
    • Medical Devices
    • Medications
    • Newborn's Delivery Information
    • Nutrition and Diet
    • Observations
    • Ophthalmic Data
    • Orders
    • Organization
    • Outcomes
    • Patient Demographics/Information
    • Patient Summary and Plan
    • Pregnancy Information
    • Problems
    • Procedures
    • Provenance
    • Recorded Sex or Gender Class
    • Referral
    • Research Data
    • Security Label
    • Sex For Clinical Use
    • Smoking Status
    • Social Determinants of Health
    • Social History
    • Special Alerts for Care Handoffs
    • Substance Use
    • Travel Information
    • Unique Device Identifier(s) for a Patient’s Implantable Device(s)
    • Vital Signs
    • Work Information
  • SVAP

Social History

  • Level 2

Data Element

Social History Observation
Drug Use
Sexual Activity
Refugee Status
Congregate Living

Comment

Submitted by aphillips@imoh… on 2022-04-28

Level 2 Data Class: Social History

Level 2 Data Class: Social History Level 2 Data Element: Social History Observation Level 2 Data Element: Alcohol Use Level 2 Data Element: Drug Use Level 2 Data Element: Sexual Activity Level 2 Data Element: Refugee Status Level 2 Data Element: Congregate Living IMO supports the proposed inclusion of the Level 2 data class for Social History in USCDI V3. The Level 2 Social History elements included in the submission are incorporated in eCQMs reported in CMS quality programs, represented in implemented terminology specifications such as the CDA R2 Implementation Guide, C-CDA Templates for Clinical Notes, present in standards for electronic case reporting (eCR), well documented in structured data, and incorporated in interoperability requirements for ONC certified HIT.

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Health information technology (Health IT) makes it possible for health care providers to better manage patient care through secure use and sharing of health information. Health IT includes the use of electronic health records (EHRs) instead of paper medical records to maintain people's health information.

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