Social Determinants of Health (SDOH) Assessment/Risk Assessment Note

Date of Service: [Date of service]

Author: [Author name and role]

Encounter Type: [office visit / telehealth / home visit / transitional care / other]

Patient Identifiers: [Per system standard]

Interpreter Used: [Y / N] (If yes, specify language)

Information Sources: [patient / caregiver / chart review / other] (List all that apply)

Indication for SDOH Assessment

[2–3 sentence description of clinical trigger for this assessment: suspected unmet social needs affecting diagnosis or treatment, nonadherence pattern, medication access issues, new diagnosis requiring navigation, discharge or care planning needs, quality program requirement] (State whether clinician-initiated, patient-requested, or quality program-prompted.)

Assessment Tool and Method

• Tool: [Name of standardized SDOH tool and version if applicable]
• Mode: [self-administered paper / patient portal / staff-administered interview / caregiver proxy]
• Administered by: [Role/title] | Reviewed by: [Clinician name and role]
• Date completed: [Date] (Include only if different from today's encounter)
• Declinations: [None / Entire tool declined / Specific domains declined: list domains and reason if provided] (Include only if applicable)

Domains Assessed and Findings

(For each domain: document status as Negative, Positive, Unknown, or Declined. Add brief details if positive. For negative domains, state "No difficulty reported." For declined, include reason if provided. For unknown, state what is known and plan to clarify.)

• Food insecurity: [Negative / Positive / Unknown / Declined] — [Details: timeframe, severity, or "No difficulty reported"]
• Housing insecurity: [Negative / Positive / Unknown / Declined] — [Details: stability concerns, safety tonight, alternative shelter plans]
• Transportation barriers: [Negative / Positive / Unknown / Declined] — [Details: impact on appointments, pharmacy access, work/caregiving]
• Utility difficulties: [Negative / Positive / Unknown / Declined] — [Details: shutoff risk, impact on medical equipment or temperature-sensitive medications]

Additional domains assessed: (Include only domains that were screened; remove others)

• Interpersonal safety/violence exposure: [Negative / Positive / Unknown / Declined] — [Minimal necessary details; confirm safe to discuss; document any mandatory reporting steps] (Use neutral clinical language; include only what is necessary for care coordination and safety)
• Financial strain/cost barriers: [Negative / Positive / Unknown / Declined] — [Details: affordability of visits, medications, supplies]
• Social isolation/support needs: [Negative / Positive / Unknown / Declined] — [Details: limited supports, caregiver availability]
• Employment instability: [Negative / Positive / Unknown / Declined] — [Details: job loss, schedule instability, benefits loss]
• Childcare/caregiver burden: [Negative / Positive / Unknown / Declined] — [Details: caregiving responsibilities impacting care adherence]
• Digital access: [Negative / Positive / Unknown / Declined] — [Details: device, internet, portal access limitations]

Identified Needs

(List problem-oriented social needs prioritized by urgency and impact on health. Create one entry per need.)

• [Problem label]

  • Supporting evidence: [Patient/caregiver report; tool response; other source]
  • Impact on medical care: [Medication access/adherence; appointment attendance; disease management; safety]
  • Status: [new / ongoing / worsening]
  • ICD-10-CM Z code(s): [Z code(s) if applicable] (Assign only when supported by explicit patient/caregiver report; do not infer)

(Add additional needs as indicated)

Interventions and Referrals

(Document concrete actions taken during this encounter. Only list resources or referrals actually provided.)

Interventions provided:

• [Intervention and linked domain/problem] (Examples: care management consult, warm handoff to navigator, medication plan adjusted for cost/storage barriers, appointment modality changed, safety planning initiated)

Referrals placed: (Create one entry per referral)

• Referral: [Destination/program name]

  • Reason: [Linked domain/problem]
  • Priority: [routine / urgent]
  • Patient consent to share information: [Y / N] (Specify scope if limited; do not infer consent)
  • Patient acceptance/refusal: [accepted / declined] — [If declined, note reason and alternative plan discussed]
  • Follow-up owner: [Name/role] | Expected timeframe: [Date/interval]

Resources provided:

• [Specific resource: organization/program name, contact information] (List only resources actually given to patient)

Plan Integration

[Brief paragraph describing how SDOH findings affect medical decision-making] (Include: which diagnoses or care goals are impacted, what changed in the plan because of these findings, risk considerations such as missed follow-up or nonadherence potential, and mitigation strategies implemented.)

Follow-Up

• Next SDOH reassessment: [Timeframe/date, if planned]
• Follow-up contact plan: [Who will contact; method; when]
• Resolution criteria: [What constitutes resolution or improvement for identified needs]
• Escalation plan: [Steps if urgent needs persist or worsen]