Documentation of social determinants in electronic health records with and without standardized terminologies: A comparative study:

Background:Electronic health records (EHRs) are a promising new source of population health data that may improve health outcomes. However, little is known about the extent to which social and behavioral determinants of health (SBDH) are currently documented in EHRs, including how SBDH are documented, and by whom. Standardized nursing terminologies have been developed to assess and document SBDH.Objective:We examined the documentation of SBDH in EHRs with and without standardized nursing terminologies.Methods:We carried out a review of the literature for SBDH phrases organized by topic, which were used for analyses. Key informant interviews were conducted regarding SBDH phrases.Results:In nine EHRs (six acute care, three community care) 107 SBDH phrases were documented using free text, structured text, and standardized terminologies in diverse screens and by multiple clinicians, admitting personnel, and other staff. SBDH phrases were documented using one of three standardized terminologies (N = average nu...