Collateral History 📞
On-call guide to taking a collateral history: who to ask, consent and confidentiality, psychiatric collateral and risk, what to ask by presentation, and how to document it.
🧠 When you need one
- Confusion, delirium or reduced GCS.
- Collapse, seizure or fall they cannot remember.
- Dementia, learning disability or communication difficulty.
- Psychosis, mania, behaviour change or low mood.
- Overdose or self-harm.
- Alcohol or drug use, including withdrawal risk.
- Unclear baseline before discharge, DAMA or a ceiling of care.
📞 Who to ask
- Family, partner or carer who knows them best.
- Witness to the event: bystander, ambulance crew, ward nurse.
- Nursing home staff, plus the transfer letter.
- GP: diagnoses, recent changes, medication list.
- Community pharmacy: what is actually dispensed.
- Community mental health team or key worker.
- Home care or community nursing team.
- Old notes, psychiatry letters, crisis plan, ambulance report.
🔒 Consent and confidentiality
- Ask the patient who you may speak to, if they can say.
- Listening to family is not a breach of confidentiality.
- Patient says no: share nothing. You can still listen.
- Lacks capacity: share what is needed for their care.
- Serious risk to them or others can justify sharing without consent. Involve your senior.
- Tell the source you may not be able to keep what they say from the patient.
- Confirm who you are speaking to before discussing anything.
- Next of kin do not consent for an adult unless formally appointed.
☎️ Making the call
- Read the chart first. Know what you need to find out.
- Say who you are, your role and why you are calling.
- Check they can talk now, and privately.
- Start open: "Tell me what has been happening."
- Build a timeline: when were they last well?
- Ask for examples, not labels. What does "confused" look like?
- Separate what they saw from what they were told.
- Finish with: "What worries you most?"
- Use an interpreter for family too.
📋 What to ask
- What is different from normal, and since when?
- Onset: sudden, gradual or fluctuating?
- Baseline cognition: orientation, memory, recognises family.
- Baseline function: mobility, aids, ADLs, continence.
- Home: lives with whom, stairs, carers, package of care.
- Recent changes: new medications, falls, infection, eating and drinking.
- Medications: what they actually take, missed or extra doses.
- Alcohol and drugs: amount, last use.
- Advance care plan, DNACPR or power of attorney.
🧩 Psychiatric collateral
- When were they last well? What changed first?
- Mood, sleep, appetite, self-care, work or college.
- Unusual beliefs, voices, suspiciousness, disinhibition, spending.
- Triggers: stress, loss, conflict, substances, stopped medication.
- Medication: adherence, depot due date, recent changes.
- Previous episodes: early signs, what helped, what did not.
- Previous admissions, including involuntary ones.
- Community team, key worker and crisis plan.
- Physical causes: new illness, head injury, withdrawal, new drugs.
- Personality and functioning when well.
⚠️ Risk
- Suicidal talk, plans, notes, goodbyes, giving things away.
- Previous self-harm: method, lethality, how they were found.
- Access to means: stored medication, weapons.
- Violence or threats, and towards whom.
- Children or dependants at home.
- Vulnerability: self-neglect, exploitation, debt, homelessness.
- Is home safe, and will someone be there?
- Immediate risk: tell your senior and psychiatry now.
🎯 Focus by presentation
Delirium
- Ask about
- Baseline cognition, onset, fluctuation, new medications
Collapse
- Ask about
- Before, during, after; colour, duration, jerking
Seizure
- Ask about
- Eyes, tongue, incontinence, recovery time
Fall
- Ask about
- Trip or blackout, long lie, head strike
Overdose
- Ask about
- What, how much, when; intent
Psychosis
- Ask about
- Onset, beliefs, substances, adherence
Mania
- Ask about
- Sleep, spending, risk-taking, previous episodes
Alcohol
- Ask about
- Daily intake, last drink, previous withdrawal
Not coping
- Ask about
- Baseline function, recent decline, supports
| Presentation | Ask about |
|---|---|
| Delirium | Baseline cognition, onset, fluctuation, new medications |
| Collapse | Before, during, after; colour, duration, jerking |
| Seizure | Eyes, tongue, incontinence, recovery time |
| Fall | Trip or blackout, long lie, head strike |
| Overdose | What, how much, when; intent |
| Psychosis | Onset, beliefs, substances, adherence |
| Mania | Sleep, spending, risk-taking, previous episodes |
| Alcohol | Daily intake, last drink, previous withdrawal |
| Not coping | Baseline function, recent decline, supports |
📝 Documentation
- Name, relationship and phone number of each source.
- How well they know the patient, and when they last saw them.
- Date, time, and by phone or in person.
- Write "collateral from daughter (Mary)", not "per family".
- Quote risk statements in their words.
- Record conflicting accounts side by side.
- Note what the patient agreed to share.
- Leave the number in the chart for the next team.
Note Template
Ready-to-use clinical note structure
🕒 04 / 11 / 2026 — 21:41 Collateral history Patient: [age] [sex] Admission Dx: [reason for admission] 📞 Source: • From: [name], [relationship] • Phone: [number] By: [phone / in person] • Patient agreed to contact: [Y / N / lacks capacity for this] • Knows patient: [how well, last seen] 🧾 Collateral: • Change from normal: [what, since when] • Onset: [sudden / gradual / fluctuating] • Baseline cognition: [orientation, memory] • Baseline function: [mobility, aids, ADLs, continence] • Home: [lives with, carers, package of care] • Medications: [as taken, missed or extra doses] • Alcohol / drugs: [amount, last use] • Witnessed event: [before, during, after] • Mental state: [last well, mood, sleep, beliefs, adherence] • Risk: [self-harm, means, others, dependants, home safe] • Mental health team: [key worker, crisis plan] • Advance care plan / DNACPR / attorney: [Y / N] 📋 Impression: [how this changes the working diagnosis or plan] 📌 Plan: • [actions arising] • Information shared with source: [none / what] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer