Inclusion criteria
- Adults aged 16 years or older unless locally adapted.
- Handover episodes involving adult inpatient, assessment unit, ED, SDEC, ward or out-of-hours care.
- Shift-to-shift handovers.
- Ward-to-ward transfer handovers.
- Team-to-team handovers.
- Weekend handovers.
- Out-of-hours handovers.
- Escalation handovers to senior teams, critical care outreach, hospital at night or specialty teams.
- Discharge or transfer handover episodes where locally included.
- Electronic, paper or hybrid handover records depending on local setup.
Exclusion criteria
- Patients under 16 years old unless locally adapted.
- Maternity-specific handovers unless locally adapted.
- Theatre, anaesthetic or critical care handovers unless locally adapted.
- Community-only handovers unless local scope includes them.
- Informal verbal updates not expected to be documented under local policy, unless specifically included.
- Duplicate records or duplicate handover episodes.
- Handovers outside the selected audit period.
- Records unavailable for review.
- Cases where local governance approval is required but has not been obtained.
- Direct patient identifiers entered into the tool.
Audit standards
GMC Good medical practice (continuity and coordination of care), NICE NG27, NICE QS136 and local clinical handover policy.
- At least 90% of handover episodes should document the handover type and receiving team.
- At least 90% should document current clinical situation and relevant background.
- At least 90% should document outstanding tasks.
- At least 90% should document task owner and expected next action.
- At least 90% should document urgency, deadline or review timeframe where relevant.
- At least 90% should document escalation or contingency plans where relevant.
- At least 90% should document key patient safety risks where relevant.
- At least 90% should have documentation clear enough for the receiving team to continue care safely.
- At least 90% should have handover-related safety concerns escalated or actioned where identified.
Audit criteria (27)
Responses are Yes, No, Not applicable or Unable to determine. Not applicable and Unable to determine are excluded from compliance denominators.
1
Handover type was documented.
Target ≥ 90%
2
Handover date and time were documented where required.
Target ≥ 90%
3
Handover recipient or receiving team was documented.
Target ≥ 90%
4
Patient location was documented without entering direct identifiers into the audit tool.
Target ≥ 90%
5
Responsible clinical team was documented.
Target ≥ 90%
6
Responsible consultant or senior clinician was documented where relevant.
Target ≥ 90% · assessed where relevant
7
Current clinical situation was documented.
Target ≥ 90%
8
Relevant background was documented.
Target ≥ 90%
9
Working diagnosis or active problem list was documented.
Target ≥ 90%
10
Current assessment or clinical concern was documented.
Target ≥ 90%
11
Handover priority or urgency was documented.
Target ≥ 90%
12
NEWS2, deterioration risk or clinical instability was documented where relevant.
Target ≥ 90% · assessed where relevant
13
Escalation plan was documented where relevant.
Target ≥ 90% · assessed where relevant
14
Treatment escalation status, ceiling of care, DNACPR, ReSPECT or TEP status was documented where relevant.
Target ≥ 90% · assessed where relevant
15
Pending investigations or results were documented where relevant.
Target ≥ 90% · assessed where relevant
16
Outstanding tasks were documented.
Target ≥ 90%
17
Task owner was documented.
Target ≥ 90%
18
Expected action or next step was documented.
Target ≥ 90%
19
Deadline, review time or required timeframe was documented where relevant.
Target ≥ 90% · assessed where relevant
20
Contingency plan or criteria for re-escalation were documented where relevant.
Target ≥ 90% · assessed where relevant
21
Medication, allergy or high-risk prescribing issues were documented where relevant.
Target ≥ 90% · assessed where relevant
22
Infection control, safeguarding, mental capacity or communication risks were documented where relevant.
Target ≥ 90% · assessed where relevant
23
Patient or family communication issues were documented where relevant.
Target ≥ 90% · assessed where relevant
24
Handover was acknowledged, accepted or closed-loop confirmation was documented where supported by local system.
Target ≥ 90% · assessed where relevant
25
Reason for delayed, missing or incomplete handover documentation was recorded where applicable.
Target ≥ 90% · assessed where relevant
26
Documentation was clear enough for the receiving clinician or team to continue care safely.
Target ≥ 90%
27
Any handover-related safety concern was escalated or actioned where identified.
Target ≥ 100% · assessed where relevant
Clinical safety note
This tool supports local audit, quality improvement and governance review. It does not replace clinical judgement, local handover policy, professional standards, escalation pathways, communication policy, information governance requirements, emergency response processes, critical care outreach criteria, sepsis pathways, safeguarding procedures or incident reporting. Any immediate clinical deterioration, missed escalation, unsafe handover, unresolved urgent task, safeguarding concern or patient safety concern must be escalated according to local policy. Do not enter patient names, NHS numbers, hospital numbers, full dates of birth, addresses or other direct identifiers.