Documenting collateral contacts in psychiatric care

By Selam Koch, PMHNP-BC, founder of OneStep Scribe and practicing psychiatric nurse practitioner. Published August 2026.

Collateral is clinical data, not a side conversation

A partner calls to say the patient has not slept in four nights. A school counselor emails about a 14-year-old who will not leave the nurse's office. Each changes what you do at the next visit, sometimes that afternoon.

Collateral tends to live in the least durable places in a practice: a voicemail heard in a parking lot, a sticky note, a memory. Read later by a covering clinician or a reviewer, it is usually missing, or present without the two things that make it usable: the authorization that permitted the contact, and the clinical use you made of it.

Privacy here is layered. The federal privacy rule, a separate federal rule for certain substance use disorder programs, your state confidentiality and minor consent statutes, and payer policy all apply at once, and the strictest governs. None of this is legal advice. Confirm what binds you with your state statute and your own counsel or compliance office.

One layer moved recently. The rule aligning substance use disorder program confidentiality with the general framework reached its compliance date in February 2026, so a single consent can now cover treatment, payment and operations, while limits on using those records in legal proceedings still differ. Program policy is often stricter, and in a program identified by its treatment focus even returning a call can identify someone as a patient.

Listening is not the same as sharing

Receiving information and disclosing it are governed differently, and this is the distinction most often collapsed in practice. The framework regulates what a practice discloses. It does not stop a worried mother from telling you something. Listening is not a disclosure.

Disclosure needs an authorization or another specific legal basis, and confirming that the person is a patient at all is a disclosure. The framework does permit some sharing with a family member involved in the patient's care, but your state may narrow that. Default to disclosing nothing until you can name and document the basis.

An authorization is not the only possible basis, and the three that come up most are not interchangeable. A signed release is permission from the patient, limited to what the form says. A court order is a judicial directive, and a subpoena by itself is not one. A mandatory reporting statute runs whether or not anyone consents, and reaches only what it requires. Probation officers and child protective services arrive expecting access: read the instrument with your counsel first, and chart the basis you relied on.

The four elements of a complete collateral entry

Every collateral note needs four things, and the third is usually the only one there. Every example here, table included, is fictional.

The failure mode I see most is content and nothing else: "Spoke with patient's wife re: recent behavior." That tells a later reader nothing about permission and nothing about judgment.

Attribution, and where the entry goes

Write collateral as reported speech, always. "Wife reports he stopped the lithium two weeks ago" is a statement you can support. "Patient stopped lithium two weeks ago" is one you cannot, if the patient later says otherwise. When the two accounts conflict, chart both.

Collateral obtained during a visit belongs in that visit's note, in the history of present illness with a sentence identifying the source, and again in the assessment if it drives the plan. The annotated progress note example shows how that line reads. Collateral obtained between visits belongs in its own dated entry, because backdating content into a signed note is a records integrity problem even when the content is accurate.

A worked example

Minors, and reportable information

Most states let a minor consent alone to some categories of care, commonly substance use treatment, reproductive health and, in some states, outpatient mental health above a certain age. Where the minor lawfully consented, the parent is often not the minor's personal representative for that information under the federal rule. What happens next is state law, and it varies: some states restrict parental access, some expressly preserve it, and where the state is silent the decision may fall to the treating clinician. Do not assume either direction. Confirm through the statute, your licensing board and your counsel before you release or withhold. A non-custodial parent's rights come from the custody order rather than from biology, and abuse concerns can be grounds to decline to treat a parent as the representative at all.

Chart three things for every minor: who holds legal custody and decision-making authority, what the minor consented to alone, and what the family agreed at the outset about what gets shared.

Collateral is also where reportable information usually arrives first. Child, elder and dependent adult abuse reporting duties come from state statute, run on their own clocks, and sit outside every authorization question here. A report earns its own documentation: what you were told, the statutory basis, the date and time, and who reported to which agency.

Releases, revocation and identity

• Scope. Releases can be limited by topic, document type and purpose. A release for care coordination with a therapist is not authorization to discuss the case with an employer.
• Expiration. A valid authorization has to state an expiration date or event. If the form in the chart has neither, treat it as defective and get a new one.
• Revocation. Treat a spoken revocation as effective immediately: stop disclosing that day, document it with date and time, and obtain a written revocation, since a written authorization is generally revoked in writing. Requirements differ in substance use treatment settings.
• Identity. Call back a number listed on the release rather than accepting a caller's word, and chart that you did.

Write all of it knowing the patient may read it, because collateral entries generally become part of the record a patient can request. Keep the entry clinically relevant, leave out gratuitous detail about the informant's life, and be straight with informants about where their words go. If you believe an informant could be endangered by an entry, take it to your counsel rather than leaving the contact out of the chart. And when a patient declines collateral altogether, honor it, chart the limits that places on assessing between-visit functioning, and keep taking information in while disclosing nothing.

Safety, and 988

Acute risk changes the calculation, but the exceptions are narrower and more state-specific than clinicians assume. Duty to warn and duty to protect statutes are mandatory in some states, permissive in others, absent elsewhere. Print your state's statutory language, keep it where you take calls, and have your counsel confirm how it applies.

Not every safety response is an emergency department. 988, the Suicide and Crisis Lifeline, takes calls and texts from worried family members as well as from people in crisis, and many areas have mobile crisis teams that can respond without a law enforcement contact. Offer those alongside 911, and chart which ones you gave. If you disclose under a safety rationale, document at the time what you were told, why you judged the risk imminent, what alternatives you considered, and exactly what you disclosed and to whom. The guide on suicide risk assessment documentation covers the formulation itself.

What collateral does, and does not do, for coding

Under the evaluation and management guidelines in effect since 2021, which now govern the office, facility, consultation and emergency department families alike, an independent historian counts toward the data element of medical decision making. That means someone giving history in addition to the patient, either because the patient cannot give a complete or reliable account or because a confirmatory history is judged necessary.

• The historian is one element in the first category of the data column, not a level in itself. Moderate data takes three elements from that category, or one from the second or third, and data is only one of three elements, two of which must be met at the same level.
• Family and caregiver history is the historian pathway. Discussion of management with a therapist, counselor, case manager or another prescriber is a different element, the discussion with an external professional, and it needs a completed two-way exchange. An unreturned voicemail is not one, and neither is reading their report; chart the attempt anyway, since it is clinically relevant even when it earns nothing.
• The contact has to inform the encounter you are billing. A call from three weeks ago, charted as its own contact note, does not carry forward to today's level.

To support it, the note has to show how the patient's history was limited or needed confirmation, who the source was, and what they contributed. "Spoke with mother" does none of that. "Patient could not recall the sequence of the last two medication changes; mother reviewed her calendar and reported the sertraline increase was 06/18" does all three. Write it for accuracy, not as a lever on a visit that did not require it, and no way of writing it determines how a review resolves.

Two time rules catch people. Report a psychotherapy add-on with an office visit on the same date and the level is selected on medical decision making alone, because the psychotherapy time is carved out and cannot be counted twice. A collateral call on a different date never counts toward a visit's time. See billing the 99214 with 90833.

Billing the contact itself

Family psychotherapy has its own codes by whether the patient is present, 90846 without and 90847 with. Both describe a psychotherapy service directed at the patient's treatment, both carry a typical time near 50 minutes, and payers generally apply the midpoint convention, putting the floor around 26 minutes. Gathering history, giving safety instructions and coordinating care are not psychotherapy, and the 11 minute call above is not billable as one.

Collateral time does not count toward the standalone psychotherapy codes either. Those are selected on time in psychotherapy with the patient; phone time with a relative, record review and note writing are not part of that total. See 90832 versus 90834 versus 90837.

Interactive complexity, 90785, is the add-on closest to this subject: schools, probation or child protective services involved in the encounter, a mandated report arising in session, caregiver behavior that complicates the service. Its rules are where denials start. It is never reported alone, it goes with the diagnostic evaluation codes, the psychotherapy codes and the psychotherapy add-ons to an office visit, never with an evaluation and management service where no psychotherapy was performed, and only one unit per session. The guide on the interactive complexity add-on works through it, and none of this is a statement that any contact will be paid.

The unsolicited call

Most collateral errors happen in the first fifteen seconds of a call you did not expect. Have language ready, review it with your counsel, adapt it to your state law, and keep every line conditional so that nothing presupposes the person is a patient. "I will tell her you called" concedes the treatment relationship you just declined to confirm, and it is the sentence clinicians reach for on autopilot.

Frequently asked questions

Do I need a signed release just to listen to a worried family member?

Generally no. The framework governs what you disclose, and taking information in is not a disclosure. What you cannot do without an authorization or another basis is give information back, including confirming that the person is a patient.

Should I tell the patient that a family member called?

In most ongoing outpatient care, yes, and it goes better when you set that expectation at intake and again on the call. Exceptions exist where disclosing the contact would create risk for the informant, and those need documented reasoning and a conversation with your compliance office.

Can I bill for time spent on collateral contacts?

Often not, and it depends on the service, the setting and the payer. The family psychotherapy codes describe a psychotherapy service with substantial time requirements, not a call to gather history. Collateral minutes do not count toward the standalone psychotherapy codes, nor toward an office visit's total time.

Related guides

• Suicide risk assessment documentation: what a defensible, clinically useful note contains
• Psychiatric progress note example: an annotated medication management follow-up
• 90785 interactive complexity: when the add-on applies and what the note has to show
• The psychiatric intake: the questions that build a defensible evaluation, and how to document the answers
• Can you bill 99214 and 90833 together? Yes, and here is what each code has to prove

This article is educational and reflects one clinician's understanding of coding rules at the time of writing. It is not legal, billing, or payer-specific advice, and it does not guarantee reimbursement or audit outcomes. Coding rules, payer policies, and state and federal laws change; always verify current requirements with your payers, coding resources, and compliance advisors, and consult your licensing board(s), current DEA guidance, and a healthcare attorney for licensure, consent, and controlled-substance questions. CPT is a registered trademark of the American Medical Association.