Residence, Living Situation, and Living Conditions Information Documentation in Clinical Practice

Social determinants of health (SDOH) have an important role in diagnosis, prevention, health outcomes, and quality of life. Currently, SDOH information in electronic health record (EHR) systems is often contained in unstructured text. The objective of this study is to examine an important subset of SDOH documentation for Residence, Living Situation and Living Conditions in an enterprise EHR informed by previous model representations. In addition to two publically available clinical note sources, notes created by Social Work, Physical Therapy, and Occupational Therapy, along with free text Social Documentation entries were reviewed. Sentences were classified, annotated, and evaluated once mapped to element entities and attributes. Overall, 2,491 total notes yielded 616, 813, and 30 sentences related to Residence, Living Situation, and Living Conditions. This study demonstrated the need for additional elements in the model representation, more representative values and content culminating in a more comprehensive model representation for these key SDOH