Standards for general practices

Core module

Criterion C5.3 – Clinical handover

        1. Criterion C5.3 – Clinical handover

Indicator


C5.3 A Our practice manages the handover of patient care both within the practice to
other members of the clinical team and to external care providers.

Why this is important

Clinical handover of patient care, to other members of the clinical team and to external care providers, occurs frequently in a practice.

Lack of, or inadequate, transfer of care is a major risk to patient safety. It can result in serious adverse patient outcomes, including:

  • delayed treatment
  • delayed follow-up of significant test results
  • unnecessary repeats of tests
  • medication errors.

It can also result in legal action.

Meeting this Criterion

Clinical handover needs to occur whenever there is a transfer of care from one provider to another. For example, when:

  • a practitioner is covering for a fellow practitioner who is on leave or is unexpectedly absent
  • a practitioner is covering for a part-time colleague
  • a practitioner is handing over care to another health professional, such as a nurse, physiotherapist, podiatrist or psychologist
  • a practitioner is referring a patient to a service outside the practice
  • there is a shared-care arrangement (eg a team is caring for a patient with mental health problems)
  • there is an emergency, such as handover to hospitals or ambulance
  • the patient makes a request (eg to upload their health summary to a shared electronic health record).

Whenever clinical handovers occur due to the absence of a regular practitioner, it is good practice to:

  • tell the patient who will take over their care
  • pass on information about the patient’s goals and preferences
  • support patients, carers and other relevant parties who will be involved in the clinical handover, according to the wishes of the patient.

Clinical handovers can be completed in person, over the phone, via video consultation or by conveying written information (eg in hard copy, facsimile, email or end-to-end encryption platforms).

You could consider having a policy to ensure that standard processes are followed during a handover. The policy could include:

  • how to use the progress notes in the patient’s health record during a clinical handover
  • how to have a secure clinical handover when sharing electronic health records (eg using healthcare identifiers that uniquely identify the individual patient)
  • how to give and receive information relating to home visits, after-hours services, hospital discharges and care provided by other healthcare professionals such as specialists
  • how to record the clinical handover in the consultation notes
  • how to report near misses and failures in a clinical handover
  • the use of a buddy system that enables a buddy to follow up results and correspondence and continue the care of the patient when a colleague is absent.

Meeting each Indicator

C5.3 A Our practice manages the handover of patient care both within the practice to other members of the clinical team and to external care providers.

You must:

  • keep copies of referrals to allied health services, other practitioners, specialists and ambulance staff in the patient’s health record
  • have a process for handover of care in the event of unexpected or expected leave.

You could:

  • keep records of any breakdowns in the clinical handover system that were identified and addressed
  • use a clinical software program to generate referrals that are automatically populated with a health summary. The referral must be accompanied by a statement written by the GP giving the reason for the referral
  • have a policy explaining how to conduct internal and external handovers, including to locum practitioners
  • have a standard form to be used for ambulance transfers
  • conduct face-to-face handovers, unless it is not possible
  • maintain service-level agreements with medical deputising services and after-hours cooperative arrangements, clearly setting out the responsibilities of all parties
  • have a shared-care arrangement when appropriate
  • create and document a buddy system
  • use internal messaging or internal email for clinical team members to communicate with each other
  • use software, such as patient information and management systems, that enables you to upload a patient’s shared health summary/record or event summary to the patient’s national shared electronic health record when the patient requests it.

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