Background Understanding the impact of a patient’s social history forms part of medical assessments and wider NHS data collection. To date, there has been little work examining the extent of social history recording by ambulance clinicians. The aim of this service evaluation is to examine how frequently staff complete social history fields on electronic patient records and to identify patterns in completion rate when comparing categories of call, localities of crew, conveyance or non-conveyance, and individual fields of social history data.
Method A retrospective review of one NHS ambulance trust’s electronic patient records (attended 01/01/2019 – 31/12/2019) was conducted. 10% of the records were analysed due to software limitations (n = 134434 adult cases).
Results Very few cases (<0.05%) had every field completed, with 28.6% of all cases having no fields completed at all. In 45% of cases, between 8 and 11 fields were completed. The mean number of fields completed per case was 5.79 and the median number was 7.
‘Mobility’ and ‘Home circumstances’ were the most frequently completed and ‘Sexual Orientation’ and ‘Language’ were the least.
Category of call appears to have minimal impact on completion rates. Localities and specialists had more variation, ranging from 21.3% to 49.9% with no fields completed at all.
Conclusion Social history documentation is very infrequently fully completed by frontline ambulance crews within this service. The majority of cases have a partially complete social history however, due to software limitations, it is unknown whether the same fields are consistently completed throughout these cases.
Further research, including qualitative work, is recommended to understand the low rate of recording of social history data and how this information is used by ambulance staff.
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