Documentation, Handover and Teamwork
Framing the domain
This domain tests whether your communication is complete, timely, accurate and actionable. Documentation is a legal record and a clinical tool; handover is a transfer of responsibility that must convey risk. Know the principle: if it is not documented, it is difficult to demonstrate it happened, and documentation must be contemporaneous, factual, objective and attributable.
Concepts to know
Structured handover tools such as ISBAR (identify, situation, background, assessment, recommendation); closed-loop communication and read-back for verbal orders; structured documentation frameworks; the difference between objective findings and interpretation; correcting errors with a single line, signature, date and time rather than erasing; late entries; and confidentiality of records. Teamwork concepts include role clarity, psychological safety, speaking up, graded assertiveness, and debriefing after events.
Common traps
- Handover that lists tasks but omits the current concern and the recommended action.
- Accepting a verbal order without read-back.
- Documenting opinions or speculation as fact.
- Back-dating or altering a record without indicating a late entry.
- Staying silent about a concern because of hierarchy; use graded assertiveness.
Rule of thumb and worked example
Rule of thumb: every handover should end with a clear recommendation and a named person responsible for the next action.
Worked example: Handing over a deteriorating patient: "This is Mr Lee in bed 12, I am concerned he is deteriorating - his respiratory rate has risen from 18 to 28 over two hours and he is newly confused. He had a laparotomy yesterday. My assessment is possible sepsis. I recommend you review him within the next 15 minutes, and I have taken blood cultures as ordered." The receiving clinician repeats back the concern and the timeframe.