8 Communication, Handover, and Follow-Up

Communicating clinical reasoning

A clinical update should make clear what is known, what remains uncertain, what needs to happen next, who is responsible, and when the patient should be reassessed. Organize concise communication around the current problem, relevant background, assessment, and recommended action. SBAR is one useful structure for team communication.

Explain the differential in proportion to the evidence: identify the leading possibility, important alternatives that could change management, and the findings that support or weaken them. State uncertainty plainly; do not present a working diagnosis as confirmed. For example, a clinician might explain that findings fit a viral illness best, bacterial infection is less likely but not ruled out, and pending tests and changes in fever or breathing will guide reassessment.

With patients, use understandable language, invite questions, and check understanding. Asking a patient to describe the plan in their own words can reveal misunderstandings. Include the patient’s priorities, preferences, and practical barriers when agreeing on next steps. Use local protocols and seek senior or specialist input when the condition or uncertainty warrants it.

Documenting decisions and uncertainty

Documentation should support continuity of care and make the reasoning behind decisions understandable. Record the presenting concern, key history, examination findings, and important changes over time. Include the working diagnosis and meaningful alternatives, explaining why urgent or dangerous possibilities were considered less likely or remain unresolved.

Also document tests ordered and results reviewed, as well as pending results and who will review and communicate them. Record treatments, the patient’s response, and reassessment findings. Include the rationale for escalation, admission, transfer, observation, or discharge; relevant consultations; and the agreed plan. Note follow-up arrangements, return precautions, and any patient preferences or barriers that affect the plan.

Distinguish observed facts from interpretations or provisional diagnoses. Do not imply a condition has been excluded when the evaluation only makes it less likely. State what remains uncertain and what action will address that uncertainty. Documentation should be concise but sufficient for the next clinician to continue care safely.

Escalating concerns

Escalate promptly when a patient deteriorates, a concern is time-critical, a serious possibility cannot safely be excluded, or the situation requires expertise or resources beyond the current setting. State the concern directly, provide supporting information, and make a clear request.

For urgent instructions, use closed-loop communication: the receiver repeats or confirms the message, and the sender verifies that it was understood. This helps ensure that the instruction has been received and understood.

Handing over information and responsibility

A handover transfers both information and responsibility. I-PASS is a useful structure for making that transfer complete:

1. Illness severity: State whether the patient is stable, needs close observation, or is unstable.

2. Patient summary: Describe the clinical picture, relevant background, and treatment so far.

3. Action list: Identify specific tasks, including pending tests and deadlines.

4. Situation awareness and contingency plans: Explain what changes to watch for and what to do if they occur.

5. Synthesis by receiver: Invite questions and have the receiver confirm the plan.

Whenever possible, hand over interactively and reduce interruptions. Make ownership of each outstanding task explicit so that responsibility does not become unclear.

Disposition, reassessment, and follow-up

Disposition should match the patient’s current condition, remaining risks, response to treatment, and the reliability of the proposed next step. Reassess after important interventions and before transfer or discharge by comparing symptoms, examination, and relevant observations with the initial state. If the patient has not improved as expected or new concerns arise, revisit the differential and plan rather than relying on the earlier assessment.

For discharge, explain the working diagnosis and its limits, the treatment plan, and specific instructions for when and where to seek urgent help. Arrange follow-up with a named service or clinician and a timeframe appropriate to the problem. Specify who will review pending results, how those results will reach the patient, and what will happen if follow-up or testing is not completed. Untracked referrals and results can contribute to delayed or missed diagnoses, so follow-up needs an accountable owner and a way to confirm completion.

Applying a handover to pending imaging

Consider a patient with improving abdominal pain who is being handed over while imaging is pending. A useful handover states the patient’s current stability, key examination findings and working differential, and response to treatment. It also identifies who must review the scan and by when, and what change—such as worsening pain or new instability—requires immediate reassessment. The receiving clinician confirms both the pending task and the contingency plan.