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Taking a collateral history is an important skill that can be assessed in OSCEs. This guide provides a structured approach to taking a collateral history in an OSCE setting.
Background
In most cases, it is best to take a history from the patient directly, but sometimes the patient is unable to give you the information you need, for example, if they are confused or if they lost consciousness (e.g. seizure/syncope).
In these situations, a collateral history should be taken from a close family member, friend or witness.
This should be taken as soon as possible after the patient is admitted so that an accurate diagnosis and an appropriate management plan can be made.
Before the consultation
Before approaching a patient’s family member/friend/witness for information, gain the patient’s consent if they have capacity.
It is also a good idea to review the patient’s notes so that you can confirm their history with the family member/friend/wtiness, and prioritise collecting any information that is missing.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a collateral history.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
- Demonstrating empathy in response to patient cues: both verbal and non-verbal.
- Active listening: through body language and your verbal responses to what the patient has said.
- An appropriate level of eye contact throughout the consultation.
- Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
- Making sure not to interrupt the patient throughout the consultation.
- Establishing rapport (e.g. asking the patient how they are and offering them a seat).
- Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
- Summarising at regular intervals.
Presenting complaint
If you were unable to determine the patient’s presenting complaint from the patient or their notes, you may need to ask the patient’s family member/friend/witness for more information.
Use open questioning to explore the patient’s presenting complaint.
- “Why were they brought into hospital today?”
- “Tell me about the issues they have been experiencing”
- “What did you witness occur?”
History of presenting complaint
Ask the patient’s family member/friend/witness to give you more details about the presenting complaint if they are able to.
The questions you should ask will vary depending on the presenting complaint.
Remember that the family member/friend/witness will only be able to give you information from what they have seen or what the patient has told them. For example, they would not be able to tell you how the pain feels.
A useful question to ask is: “When was the patient last well?”
This will give you an idea about whether the problem is acute or chronic. It also enables you to explore with the family member/friend/witness what has happened since then, in chronological order.
Summarising
Summarise what the family member/friend/witness has told you about the presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the family member/friend/witness to correct any inaccurate information.
Once you have summarised, ask the family member/friend/witness if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next.
Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the family member/friend/witness with time to prepare for what is coming next.
- “So far we have talked about your family member’s symptoms since they became unwell. I would now like to discuss their past medical history.”
Past medical history
Medical history
Ask the patient’s family member/friend/witness if they know whether the patient has any medical conditions.
If the patient does have a medical condition, you should gather more details to assess how controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.
Surgical history
Ask if the patient has previously undergone any surgery or procedures.
Allergies
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Drug history
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies. If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form, and route.
You should also ask whether the patient has recently started or stopped any medications because side effects or withdrawal may be contributing to their presenting complaint (e.g. seizure).
Another important question to ask is whether the patient is taking their medications as prescribed. Does the patient ever refuse their medication or forget to take it? Do they use a compliance aid?
Baseline cognition
If the patient was unable to give you their history due to confusion, it is important to determine their baseline level of cognition.
Questions you could ask the family member/friend include:
- “Does the patient usually have problems with their memory?” and if so, “How long has this been going on for?”
- “Has the patient’s behaviour changed recently? For example, have they been getting more aggressive or having hallucinations?”
- “Do they have a diagnosis of dementia?” and if not, “Are they awaiting investigations for possible dementia?”
You should also sensitively ask whether the patient could be a risk to themselves or others, for example leaving the stove on or wandering at night.
Baseline mobility
Awareness of a patient’s baseline mobility is critical when planning for a patient’s discharge.
Usually, if a patient was walking with a stick before admission, the aim is to make sure they are able to walk with a stick before discharge.
If the patient is not mobilising at their baseline during their hospital stay, they are likely to benefit from a review by a physiotherapist.
Questions you could ask the family member/friend include:
- “How far can the patient usually walk when they are well?”
- “Do they need assistance when moving around indoors? For example, do they use a walking stick, a frame, or a wheelchair?”
- “Do they need assistance when moving around outdoors? For example, do they use a walking stick, a frame, or a wheelchair?”
Living arrangements
Awareness of a patient’s home circumstances is particularly important when planning for the patient’s discharge.
Collecting this information as soon as possible after admission will help to prevent delays to the patient’s discharge, once they are medically stable.
Questions you could ask the family member/friend include:
- “Does the patient live with anyone else?”
- “Do they have informal or formal carers?” If so, “How often do they visit?” and, “Do the carers feel able to address all of the patient’s needs?”
- “What type of home does the patient live in? For example, is it a house, flat, or care home?”
- “Does their home have any stairs?” If so, “Is there a stairlift?”
- “Are there any steps into the property?”
Continence
It is important to specifically ask about incontinence because a patient’s family member/friend may not offer this information unprompted.
If a patient is incontinent during their hospital stay, it should not just be assumed that the patient is incontinent at home.
Questions you could ask the family member/friend include:
- “Is the patient usually continent of urine?”
- “Is the patient usually continent of faeces?”
- If they are not continent, “How is this usually managed at home?”
Activities of daily living
Determining which activities of daily living a patient can usually perform independently is another important aspect of the collateral history.
If the patient is unable to perform these activities independently during their hospital stay, they may benefit from a review by an occupational therapist before discharge.
Activities of daily living include:
- Washing themselves
- Dressing themselves
- Toileting themselves
- Managing medications
- Cooking
- Cleaning
- Shopping
- Managing their finances
Ask the family member/friend whether the patient can usually complete the above activities of daily living independently. If they cannot, ask who helps them with those activities.
It is also beneficial to ask whether the patient currently works or if they drive a car.
You should also ask whether the patient drinks alcohol, smokes tobacco, or uses recreational drugs.
Advance care planning
It is often useful to find out whether a patient has previously discussed their thoughts about certain medical treatments such as CPR, especially if the patient is currently unable to discuss them with you themselves.
You could sensitively ask the family member/friend the following questions:
- “Has the patient previously discussed their thoughts about CPR with their GP or someone close to them?” If so, “Does the patient have documentation of this discussion in writing?”
- “Has the patient expressed any other thoughts about medical treatments they would not want?”
- “Does the patient have a lasting power of attorney for health and welfare?”
It can also be useful to ask: “What is most important to the patient?”
The patient may wish to stay within their own home for as long as possible, or they may wish to spend as much time as they can with their spouse, for example. The answer to this question may help you to determine what would be in the patient’s best interests.
Closing the consultation
Summarise the key points back to the family member/friend.
Ask the family member/friend if they have any questions or concerns that have not been addressed.
Thank the family member/friend for their time.
Dispose of PPE appropriately and wash your hands.
Reviewer
Consultant Geriatrician
Editor
Dr Chris Jefferies
References
- Fitzpatrick D, Doyle K, Finn G, Gallagher P. The collateral history: an overlooked core clinical skill. Published 23 July 2020. Available from: [LINK]
