Collateral Information
When you are interviewing the patient directly, you are getting her firsthand account of how she has been feeling, what brought her to the ER, and what her past history has been. This information is extremely valuable—you need to know how she perceives her symptoms. She is giving you a lot of diagnostic information that will be helpful in determining your next step in management. However, there are many times in which collateral information gives you extremely important information in treating the patient—information that you may not have known otherwise (Jacobs et al. 2003).
You may be wondering why that is. After all, you have just conducted a very thorough interview of the patient, and asked all the relevant questions. The patient has answered all the questions, and now you feel you’re ready to sum it up, write your note, and get that patient the treatment he needs. You’re feeling pretty good about your interview, and feel you are ready to make your decision about the next step in treatment. You’re right—you have obtained a significant amount of data already. However, there is one more aspect to the interview process that can be extremely helpful to understanding and treating your patient. And that is collateral information.
When a patient is experiencing an acute episode of illness, it may be hard for him to give you an accurate depiction of his symptoms. If he is depressed, he may have trouble remembering all of his symptoms. He may be unable to give you a depiction of how his symptoms have changed over time. If he is manic, he may have very limited insight into the fact that he is manic right now. If he is paranoid, he may be suspicious about what you will do with the information he gives you, and he may not tell you exactly what’s on his mind. These are just some examples of how the illness itself could limit the amount of information you are given. The patient also may have feelings about being in the ER, and may either minimize or enhance his depiction of the symptoms when portraying them to you. The patient may have difficulty remembering exactly what happened the last time he was hospitalized, or what medication he had been on in the past. Remember that this is likely a stressful time for the patient!
In order to get a more precise idea of both the patient’s current presentation and past history, collateral information can be very helpful. Family members, friends, roommates, and anyone else who is close to the patient may be able to give you more information on how the patient has been doing in the time period leading up to the current ER visit. For example, he may have told you he has been feeling down for a while and not sleeping too well, but otherwise feeling alright. Then, when you ask his wife how she feels he has been doing, she tells you that she has to remind him to bathe and brush his teeth, he has been more irritable with their children, and he seems to be staring off into space and talking to someone who is not there at times. This would help you to understand the depth of his depression more fully, and also then to consider that the patient may be internally preoccupied. You would then want to ask the patient more questions about potential auditory hallucinations.
Family members can also be helpful in telling you if current symptoms are similar to previous episodes of symptom exacerbation. Is this the first time the patient’s wife has noticed these symptoms of depression? If he has had them before, are these symptoms similar to the ones he has had in the past? Stronger? Different in any way? Along these lines, if the patient is currently undergoing outpatient mental health treatment, try to contact the patient’s current providers. They can offer further information on diagnosis, any current medications, and past treatment. They can also give you an idea of how the patient has been doing in treatment, and if they have noticed any recent changes.
Another potential resource is past psychiatric records, if they are available to you. If the patient has been in mental health treatment at your hospital before (ER, inpatient, outpatient), make sure you review those records. If the patient has been in treatment elsewhere, see if you can get access to those records or speak with someone who was involved in the treatment. If the patient is currently on parole or assigned to court-mandated treatment, reach out to the parole officer or team involved in court-mandated treatment to get more information. If the patient is living in a residence or group home, contact the staff there. All of this information together will help you to get a more complete understanding of your patient. The more you can understand your patient, the better you can treat your patient. This is highly beneficial for both you and the patient, as it can ensure the best possible treatment.
Keep in mind that sometimes it is not possible to get any collateral information. An example of this might be a patient who is homeless, and was brought in by the police after getting in a verbal altercation on the street. The police have left the hospital by the time you are interviewing the patient. You try to call the police station, but the officers who brought the patient in are now off duty. When you speak to the patient, he tells you he has no family, is not in outpatient treatment, and moves around from shelter to shelter. In this case, your interview of the patient will be the sole source of diagnostic information. That’s okay—this is why you conduct a thorough interview, and pay attention to both the patient’s verbal interview and mental status.
Another thing to keep in mind is the patient’s privacy, and use your discretion in obtaining collateral information. If family members bring the patient to the ER, it can be quite helpful to get their account of the patient’s symptoms leading up to this visit. If the patient comes in without a family member but lives with others, you may want to contact them to find out more information. However, you should only contact those people that you need to speak with to get information that is relevant to your treatment of the patient. Medical and mental health providers and staff that work with the patient (like in a group home or residence) are helpful to contact as well.
