# How Healthcare Teams Strengthen Patient Care Handoffs - Published: 2026-11-09 - Author: [Doctors Magazine](https://doctorsmagazine.co/author/doctorsmagazine-co.md) - Topics: [Q&A](https://doctorsmagazine.co/qa.md) - Source: https://doctorsmagazine.co/qa/how-healthcare-teams-strengthen-patient-care-handoffs/ - Publication: Doctors Magazine - Publisher: Connectively (Terkel, Inc.) - Editorial policy: https://doctorsmagazine.co/editorial-policy/ - AI use: The perspectives in this article were written by the named contributors and submitted through Connectively. Connectively's automated system selected them and used AI to write the headline, introduction, section headings, summary sections, and illustration, and to make minor edits for clarity. Articles are assembled and published automatically. Report errors to corrections@connectively.us. ### Use Checklists to Assign Ownership I've found that the most reliable handoffs happen when the next clinician can quickly understand not just what has happened, but what still needs to be done. Whether a patient is moving from urgent care to primary care or being referred to another provider, I focus on communicating the reason for the visit, key findings, relevant medications, pending test results, and the next steps in the care plan. A detailed chart is helpful, but the most important information needs to be easy to find, especially when the receiving clinician has limited time. The practice that has made handoffs more reliable is using a consistent checklist that clearly identifies outstanding tasks and who is responsible for them. Research published in AHRQ's Patient Safety Network found that, following implementation of a modified I-PASS handoff tool in a pediatric emergency department, staff-reported loss of key patient information during handoffs fell from 75% to 37.5%. I pay particular attention to pending results, medication changes, and follow-up that cannot be left open-ended. Whenever possible, I make the next action explicit rather than assuming the receiving team will work it out from the notes. I've found that a good handoff is not simply about transferring information. It is about making sure responsibility is clear, so the patient does not fall through the cracks during a transition in care. --- ### Send Visual Referral Packets The handoff that fails most often in my field is the referral for a suspicious skin lesion, whether it goes to a Mohs surgeon, a surgical oncologist, or a pathologist. The lesion lives in a photo and a biopsy report, so a handoff that omits either one costs the next clinician time and costs the patient safety. The practice that made these handoffs reliable is a single closed-loop packet that leaves my office with every referral. It holds a labeled photo of the lesion with a ruler beside it, a body map that marks the exact site, the pathology report, the medication list with blood thinners flagged, and a two-line summary that states what I found and what I need the next clinician to do. The site matters most. Surgeons have operated on the wrong spot when a note said left cheek and the scar had healed to nothing, so the photo and the map carry the answer. The loop closes on my side. My staff tracks every referral until the receiving office confirms it saw the patient, and a missing confirmation within two weeks triggers a call. Patients leave with the same packet and a plain-language sentence about who they will see and why, so they can prompt anyone who forgets. The habit applies far beyond dermatology. A handoff works when the sender assumes the receiver has none of the context, and when the sender keeps responsibility until the receiver acknowledges it. --- ### Demand Read-Back for Urgent Risks 1\. My father is in rehab after hip surgery, and I stopped trusting the system to carry the information for his care after I read his discharge summary from the hospital 2 days after he actually left for rehab. The rehab nurse's meds list still had the blood thinner that had been discontinued for my father in the hospital. I have been keeping a one-page summary of current medications (with dose and date of change), allergies, surgeon's orders to watch for, and contact numbers for my father's many caregivers. This one-page summary is carried by the facility and I hand-carry it to all of his new caregivers. 2\. The practice that makes handoffs work well is read-back. So I ask the nurse or doctor who is taking over for me to tell me in their own words the 2-3 things that could kill my father in the next 24 hours. If they can't do that, then even though information has been handed off and entered into the chart, handoff has not occurred yet. I make sure that every change, etc. has a date and a name next to it. "He stopped warfarin" is useless information. "He stopped warfarin 3/14. Dr. Lim. Bleeding risk." Then someone else can take action without having to guess. In my experience, the vast majority of near mistakes are due to information that has been entered a long time ago and which still appears to be current. --- ### Clarify Orthopedic Recovery Orders In orthopaedic care, a patient's treatment often involves several people, from the surgeon and nursing team to physiotherapists and other specialists. I believe a reliable handoff starts with making sure the next person understands not just the diagnosis, but also what has been done, what still needs attention, and what to watch for. For example, after a fracture or joint replacement, important details include the patient's weight-bearing instructions, current medications, wound-care needs, rehabilitation plan, and any warning signs that require prompt attention. If these details are unclear, even a small misunderstanding can affect recovery. One practice that makes handoffs more reliable is using a consistent checklist and confirming that the receiving clinician understands the key points. I would rather spend an extra minute clarifying an instruction than leave room for confusion later. Written notes are important, but they should be supported by direct communication when the case is complex or the patient's condition has changed. For me, a good handoff means the next person can continue care confidently without having to guess what happened before. Ultimately, continuity of care depends on clear communication and shared responsibility for the patient's recovery. --- ### Answer Three Questions at Every Transfer When a patient's care moves from one clinician to another, even a small detail can make a difference in what happens next. I've found that simply passing along medical records isn't always enough. The receiving clinician needs to understand why certain decisions were made, what concerns still need attention, and what the patient should expect next. Our team tries to keep these conversations clear and focused so important information doesn't get lost during the transition. A practice we find particularly helpful is making sure every handoff answers three questions: What's happening with the patient right now? What needs attention next? And who is responsible for following through? This gives the next clinician a clearer picture rather than leaving them to piece everything together from notes. I've learned that a reliable handoff isn't about sharing more information, but making sure the right information reaches the right person at the right time. --- ### Update Hormonal Health Snapshots As a reproductive endocrinologist, the handoffs that work best all share one thing. A short summary updated right before the handoff. I call it a hormonal and sexual health snapshot. On busy days this keeps colleagues from digging through charts. You see the key diagnoses, current therapies, and next steps at a glance. When you want the next clinician to move fast and feel confident, a current summary beats everything else. If you have any questions, feel free to reach out to my personal email --- ### Set Explicit Alert Thresholds The practice that made our handoffs most reliable is ending every handover with one explicit sentence: "Call the doctor if..." followed by concrete thresholds for that specific patient. A rising withdrawal score above a set level, blood pressure above a set value, any confusion, any mention of self-harm. Before we did this, handovers were full of information but light on decisions. The incoming nurse knew what had happened but not what should trigger action, so they either called too often about minor things or hesitated about important ones. With clear thresholds, the next person can act confidently without having to guess what the previous clinician was worried about. We also hand over at the bedside where possible, briefly and with the patient's involvement. Patients often add something important that was missing from the notes, such as "I didn't sleep at all last night" or "I feel worse than I said earlier". A written summary covers the facts. The bedside conversation catches what the summary missed. --- ### State Surgical Escalation Plans A reliable handoff should tell the next clinician not only what has happened, but what they need to watch for and what action to take if the patient's condition changes. In general surgery, this is especially important when patients transition from the operating room to postoperative care or return home after a procedure. A surgical report may document everything accurately, but the receiving clinician still needs to understand the immediate priorities, including potential complications, expected recovery milestones, and any findings that require follow-up. One practice I consider particularly valuable is a brief, structured handoff that ends with confirmation of the next steps. Rather than simply listing clinical findings, I would emphasize what needs attention, who is responsible, and when a concern should be escalated. For example, after abdominal surgery, communicating the expected recovery course alongside specific warning signs helps the next clinician distinguish routine postoperative discomfort from a problem requiring reassessment. The goal is to eliminate guesswork. A successful handoff is not measured by how much information is transferred, but by whether the receiving clinician can make the next decision confidently and safely. --- ### Apply SBAR to Define Accountability A patient-care handoff is only effective when the receiving clinician understands not just what has happened, but what needs to happen next. In obstetrics and gynecology, where a patient's condition can change rapidly, this clarity is essential for safe and timely decisions. One of the most effective approaches is a structured handoff using SBAR (Situation, Background, Assessment, Recommendation), supported by clear documentation and direct communication between clinicians. Consider a pregnant woman being referred for severe hypertension. Simply mentioning her diagnosis is not enough. The receiving team needs her gestational age, recent blood pressure readings, relevant laboratory results, medications already administered, maternal and fetal assessment findings, and any signs suggesting deterioration. Equally important is explaining what requires immediate monitoring and which decisions cannot safely be delayed. A particularly useful safeguard is closing the communication loop. Rather than assuming the information has been understood, the transferring clinician should confirm that the receiving clinician knows the immediate priorities, pending investigations, and who is responsible for following up on results. Written records provide continuity, but a direct conversation allows clinicians to clarify concerns that may not be obvious from the documentation alone. In my view, the most reliable handoffs prioritize three things: the patient's current clinical status, the risks that could develop next, and the specific actions required from the receiving team. The goal is not to communicate every detail of a patient's history, but to ensure that critical information is understood and responsibility for the next steps is clear. ## Related - [Clinical Handoffs That Keep Patient Care Continuous](https://doctorsmagazine.co/qa/clinical-handoffs-that-keep-patient-care-continuous.md) - [Make Hospital Discharge Stick: Hospital-to-Clinic Handoffs That Cut Confusion](https://doctorsmagazine.co/qa/make-hospital-discharge-stick-hospital-to-clinic-handoffs-that-cut-confusion.md) - [How Healthcare Teams Delegate Patient Care Safely](https://doctorsmagazine.co/qa/how-healthcare-teams-delegate-patient-care-safely.md) - [16 Unexpected Benefits of Electronic Health Records That Changed My Perspective on Digital Documentation](https://doctorsmagazine.co/qa/16-unexpected-benefits-of-electronic-health-records-that-changed-my-perspective-on-digital-documentation.md)