SDOH Screening & Social Referrals — User Guide

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Overview

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Table of Contents

• Key Capabilities
• Decision Tree
• Quick Reference
• Pattern Library
• Common Mistakes
• Pre-Flight Checklist
• Permissions
• Accessing the SDOH Tab
• Conducting a Screening
• Creating a Referral
• Recording a Referral Outcome
• Referral Status Lifecycle
• Z-Code Documentation (ICD-10-CM Z55–Z65)
• Code Example
• Tips & Best Practices
• Troubleshooting
• Related Documentation

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Key Capabilities

• Conduct screenings using standardized instruments (PRAPARE, AHC-HRSN) or custom tools
• Identify social needs across 12 categories (housing, food, transportation, etc.)
• Create referrals to community resources linked to specific needs
• Track referral outcomes through a status lifecycle (referred → resolved/declined)
• Document ICD-10-CM Z-codes (Z55–Z65) for social determinants via PF-70 code library

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Decision Tree

1. Need to assess social needs now?
   • Yes → Conduct screening (PRAPARE/AHC-HRSN/custom).
2. Screening identifies unmet needs?
   • Yes → Create referral linked to screening.
3. External resource engagement progresses?
   • Update referral outcome status until terminal state (resolved, declined, unable_to_reach).
4. Need formal coding for social determinants?
   • Use PF-70 type-ahead to document ICD-10 Z-codes.

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Quick Reference

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Pattern Library

• Screening dialog pattern: instrument + date + need toggles + notes.
• Referral creation pattern: need-linked referral with optional screening linkage.
• Outcome lifecycle pattern: status progression with clinical outcome notes.
• Coding pattern: PF-70 code lookup for ICD-10 Z55–Z65 documentation.

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Common Mistakes

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Pre-Flight Checklist

• Confirm chart-level access and required SDOH permissions.
• Validate patient contact details before referral submission.
• Verify disclosure basis (authorization or permitted exception) is documented.
• Confirm resource-to-need match and referral notes completeness.
• Add appropriate Z-code documentation where clinically indicated.

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Permissions

Note: The org_admin role automatically receives all permissions. The readonly role can view but not create or modify records.

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Accessing the SDOH Tab

1. Navigate to a Patient Chart (Clinical → Charts → select patient).
2. Click the SDOH tab in the chart tab bar.
   • If the tab is not visible, you may lack the cl.sdoh_screenings.view permission. Contact your administrator.

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Conducting a Screening

1. On the SDOH tab, click Conduct Screening.
2. In the dialog:
   • Instrument: Select the screening tool used (PRAPARE, AHC-HRSN, or Custom).
   • Date: Set the screening date (defaults to today).
   • Identified Needs: Click the need category badges to toggle them on/off. Selected needs appear highlighted. Categories include:
     • Housing Instability, Food Insecurity, Transportation, Employment, Education/Literacy, Childcare, Utilities, Personal Safety, Social Isolation, Financial Strain, Legal Issues, Other
   • Notes: Add any additional screening observations.
3. Click Record Screening to save.

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Creating a Referral

PHI Disclosure Notice: Creating a referral may involve sharing patient information with an external community organization. Before submission, confirm and document the applicable disclosure basis (patient authorization and/or permitted regulatory exception per local policy). The referral workflow may transmit patient identifiers, contact details, linked social-need category, and referral notes to the external resource. The current application enforces role permissions (cl.social_referrals.create) but does not independently guarantee legal disclosure basis validation; clinicians/staff must verify this as part of workflow policy. Refer to your organization’s Notice of Privacy Practices and compliance guidance before sending referrals externally.

1. On the SDOH tab, scroll to the Social Referrals section and click Create Referral.
2. In the dialog:
   • Resource Name (required): Name of the community resource or agency.
   • Resource Type: Type of resource (e.g., shelter, food bank, legal aid).
   • Need Category (required): The social need this referral addresses.
   • Linked Screening: Optionally link to a prior screening that identified this need.
   • Notes: Additional referral details.
3. Click Create Referral to save.

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Recording a Referral Outcome

1. In the Social Referrals table, click the arrow icon (→) on the referral row you want to update.
   • This button is only visible if you have the cl.social_referrals.update permission.
2. In the outcome dialog:
   • Status: Select the new status:
     • Contacted — Initial outreach made
     • In Progress — Referral is actively being worked
     • Resolved — Need was successfully addressed
     • Declined — Patient declined the referral
     • Unable to Reach — Could not contact the resource or patient
   • Outcome Date: When the outcome occurred.
   • Outcome Notes: Document what happened.
3. Click Record Outcome to save.

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Referral Status Lifecycle

referred → contacted → in_progress → resolved
                                    → declined
                                    → unable_to_reach

• referred → contacted or directly to resolved / declined / unable_to_reach
• contacted → in_progress or directly to resolved / declined / unable_to_reach
• in_progress → resolved / declined / unable_to_reach

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Z-Code Documentation (ICD-10-CM Z55–Z65)

Note: Z-code selection is available as a standalone component and will be integrated into screening and problem list workflows in a future release.

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Code Example

// Example: create referral and record related SDOH Z-code (PF-70-assisted lookup)
const referralPayload = {
  chartId,
  needCategory: 'housing_instability',
  resourceName: 'City Housing Support Network',
  linkedScreeningId,
};

// 1) Save referral
await createSocialReferral(referralPayload);

// 2) Persist ICD-10 Z-code selected from PF-70 type-ahead (example: Z59.0)
await addSdohProblemCode({
  chartId,
  code: 'Z59.0',
  codingSource: 'pf70',
});

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Tips & Best Practices

• Screen at intake and periodically: SDOH screenings should be conducted at admission and at regular intervals (e.g., every 90 days) to track changes in social needs.
• Link referrals to screenings: When creating a referral, linking it to the screening that identified the need provides a clear audit trail.
• Follow up on referrals: Use the outcome recording feature to track whether referrals result in successful connections to resources.
• Use standardized instruments: PRAPARE and AHC-HRSN are validated, evidence-based tools. Use “Custom” only when a standardized instrument doesn’t fit.

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Troubleshooting

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Related Documentation

• CL-18 Integration Doc
• PF-70 Medical Terminology