Closing the Gaps: A Team-Centered Approach to SDOH Documentation for Better Health Outcomes

As the healthcare industry continues its shift toward whole-person care, the accurate and efficient documentation of social determinants of health (SDOH) has never been more important. This year, AHIMA issued a member-exclusive resource, “Social Determinants of Health: Identifying Documentation Gaps in Workflow,” to provide a comprehensive and actionable framework for health information (HI) professionals, clinical teams, and organizational leaders.

While not formally part of the AHIMA Data for Better Health (D4BH) initiative, this guide is featured on the initiative’s website and strongly aligns with its overarching goals, highlighting how accurate SDOH data capture supports equitable care delivery, population health improvement, and informed policymaking.

SDOH refers to the social and environmental conditions in which people live, learn, work, play, and age; factors that can either promote or hinder health and well-being, according to the Centers for Disease Control and Prevention (CDC). The CDC, World Health Organization (WHO), and AHIMA each emphasize that these non-clinical elements, from housing and food insecurity to transportation access and interpersonal safety, significantly influence health outcomes. In addition, the Healthy People 2030 initiative identifies SDOH as one of five key priority areas for action, highlighting the need to address nonmedical factors that influence health outcomes across populations.

For HI professionals, the implications are clear: our role extends beyond compliance. We are uniquely positioned to influence how data is captured, where it flows, and how it is used to shape better health outcomes. As trusted stewards of health data, we must continue leading the charge in closing documentation gaps and building more equitable systems.

The Need for Consistent SDOH Documentation

Despite growing awareness, the healthcare system continues to struggle with inconsistent SDOH documentation. Gaps occur at every level including non-standardized patient assessments, inconsistent workflows, lack of staff training, siloed systems, and uneven leadership engagement.

The AHIMA resource outlines key barriers, including:

• Lack of standardization in data capture and documentation processes
• Misunderstanding of the role of SDOH data; staff may assume they are responsible for solving patients’ social challenges instead of connecting them to resources
• Training deficits around implicit bias and patient-centered communication
• Insufficient follow-up to track and evaluate the impact of interventions
• Minimal leadership oversight, resulting in fragmented or unclear workflows

These gaps do not just affect internal processes; they contribute to missed opportunities in patient care, ineffective resource allocation, and lost chances to inform policy and funding decisions that could benefit vulnerable populations.

The guide proposes a team-centered approach to embedding SDOH data capture within existing workflows. Its strength lies in its practical applicability, offering a model workflow that aligns each step of the patient’s journey, from pre-admission to discharge and follow-up. This process maps responsibilities across roles, including clinicians, social workers, coders, and non-clinical staff, ensuring the information is collected, acted upon, and included on the claim when appropriate.

A sample visit might look like this:

1. The patient receives a screening form through the portal before their visit.
2. At check-in, staff prompt the patient to review or update responses.
3. A medical assistant confirms and escalates relevant issues.
4. The provider discusses results and, if necessary, refers to a case manager or social worker.
5. The social worker initiates referrals and ensures the information is captured in a codable format.
6. The coder reviews the signed-off information, assigning appropriate ICD-10 CM Z codes for claim submission.

Leadership and Teamwork Make a Difference

Each team member plays a crucial role, and the guide reinforces the need for leadership involvement to drive consistency, accountability, and cross-departmental coordination.

AHIMA’s guide also places SDOH documentation within the broader regulatory landscape. For example:

• The Centers for Medicare & Medicaid Services (CMS) requires screening for five health-related social needs (HRSNs), including housing and food insecurity, transportation barriers, and safety concerns.
• The federal Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing (v3) mandates that certified health IT must include standardized SDOH data elements as of January 2025.
• The Joint Commission’s Health Equity Standards require accredited providers to assess and address disparities in patient care.

Meeting these mandates demands integrated data systems, a shared organizational understanding, and clarity around roles and processes, all of which are addressed in the team-based approach by AHIMA.

The Data for Better Health initiative further amplifies the value of structured, actionable SDOH data. The initiative advocates for:

• Standardized data capture, enabling cross-sector collaboration and population-level reporting
• Accessible, codable formats that support policy advocacy and financial alignment
• Electronic health record (EHR) interoperability, allowing data to move with the patient and inform care across settings.

When combined with policy levers and quality measures, SDOH data becomes a powerful tool to drive system-level improvements and resource alignment, especially when codified and submitted through standardized billing processes.

The work doesn’t stop at documentation. The guide encourages organizations to reflect on their internal processes, evaluate staff training, and reassess the visibility of community-based resources. It also highlights the need for discrete data fields, integrated EHR workflows, and collaboration with referral platforms like Aunt Bertha (now Findhelp), Neighborhood Navigator, and UniteUs.

The AHIMA resource on SDOH is more than a guide; it is a call to action. It challenges health organizations to elevate SDOH documentation from a box-checking exercise to a core part of care delivery. With its actionable workflow, regulatory context, and alignment with DB4H principles, this guide empowers professionals across disciplines to turn data into impact.

As we look at 2025 and beyond, the message is clear: Better data for better health begins with purposeful, informed documentation, because we ask, we act, and above all, we care.

Jennifer Mueller, MBA, RHIA, SHIMSS, FACHE, FAHIMA, FACHDM, is Senior Vice President of Health Information Career Advancement at AHIMA.