Information about a patient's medical history or current condition gathered from sources other than the patient themselves, in this case, family members and nursing staff.
Useful when the patient is unable to provide a complete history themselves, such as in cases of altered mental status, cognitive impairment, or communication barriers.
"Patient presents with altered mental status. Collateral history obtained from family members and nursing staff indicates a history of hypertension and recent falls."
Used to document the source and content of supplemental information about the patient's condition.
Common questions about using medical phrases in clinical documentation