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Hand-Off Communication (3.3.1)

Hand-Off Communication (3.3.1) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Communication


Policy Title: Hand-Off Communication
Policy Number: 3.3.1
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: July 9, 2015


To provide consistent, accurate, timely and unambiguous communication betw een health care personnel
including the opportunity to ask and respond to questions w hen a patient leaves one department to go to
another department w ithin the organization, w hen there is a change in patient caregivers, or w hen the
patient is transferred outside the organization. The goal of hand-off processes is to improve patient safety
through accurate, timely and reliable communication.


A. Hand-off: A transfer and acceptance of patient care responsibility from one caregiver to another caregiver.

The sender is responsible for sending or transmitting the patient data and releasing the care of the patient to
the receiver, w ho receives the patient data and accepts the care of the patient.

B. Hand-off communications: A reliable form of communication allow ing the opportunity for questioning
betw een the sender and receiver of patient information including up-to-date information regarding the
patient’s care, treatment and services, condition and any recent or anticipated changes for the purpose of
ensuring the continuity and safety of the patient’s care.
C. Hand-off Tool: is a standardized approach, e.g. a framew ork or method, of performing a hand-off
communication. These are useful for framing any conversation, including critical ones that need a
caregiver’s immediate attention, and it can be adapted to w ork in many situations. Examples include but are
not limited to:
i. SBAR: Situation, Background, Assessment, Recommendation
ii. I-PASS: Illness severity, Patient Summary, Action List, Situational Aw areness, and Contingency
Planning and Synthesis by Receiver
iii. IDEAL:
a. Identify patient and physician name or service,
b. Diagnosis and current condition,
c. (Recent) Events / changes in condition or treatment,
d. Anticipated changes in condition or treatment, w hat to w atch for in next interval of care,
contingency plans,
e. Leave time for the opportunity to ask questions and clarify information

A. The primary objective of a "hand-off" is to provide accurate information about a patient's care, treatment and
services, current condition and any recent or anticipated changes. The information communicated during a
hand-off must be accurate and interruptions should be minimized in order to meet patient safety needs. The
hand-off sender w ill include the information appropriate to his/her scope of practice; completeness of
information included w ill vary by situation and setting. The receiver of information should be able to review
historical data about the patient's care, treatment and services. The medical record (electronic and/or hard
copy) must be available.
At a minimum, hand-off communication content must cover all of the 5 elements in the “IDEAL” acronym
B. Hand-off communications must allow for the opportunity to ask and respond to questions. Synchronous (at
the same time/interactive), face to face communication betw een the sender and receiver is encouraged but
alternate methods can be used such as communication by phone, video or audiotaped message, fax,
email/electronic, or other w ritten means.

Policy Title: Hand-Off Communication
Policy Number: 3.3.1

i. Direct caregivers w ho do not provide 24/7 services (e.g., physical therapy) may provide a w ritten
handoff progress note that includes at least the f ive IDEAL standard elements including contact
information w here the receiver may obtain information or clarif ication.
ii. When an asynchronous hand-off communication occurs (not at the same time, e.g. email, progress
note in electronic health record), the sender must leave contact information and be available to
answ er questions and clarify information for the receiver.
iii. Synchronous communication is strongly recommended w hen the patient condition is rapidly
changing or the patient is critically ill.
C. Hand-off communication is expected to occur using a standardized approach, either by discipline or in an
interdisciplinary fashion, for transitions of patient care responsibility occurring w hen a patient physically
changes care location and/or a caregiver changes including but not limited to:
i. Change in level of care
a. Inpatient admission from the Emergency Department (ED), clinic, or procedure area
b. Transfer to/from ICU, intermediate care and general care
c. Transfer from a clinic to the ED
d. Post-procedure by Anesthesia caregiver to Post Anesthesia Care Unit or Intensive Care
Unit caregivers.
ii. Temporary transfer of care
a. From inpatient, clinic, or ED to Operating Room, procedure area, diagnostic area
b. Relief of staff member leaving the care of the patient for a short period of time, i.e., lunch,
break, or patient road-trip.
iii. Hospital admission, transfer and discharge
a. Communication to next caregiver (if know n) at inpatient discharge
b. Communication to Home Health caregiver
c. Communication to transfer facility (skilled nursing facility, Assisted Living Facility, another
iv. Change in caregiver or change in service
a. RN, physician (attending, resident or fellow ), advanced practice professional (APP)
change of shift or on-call caregiver
b. Clinical rotation change (resident/fellow physician, attending physician, APP)
D. Acknow ledgement of the handoff w ill be made as appropriate to discipline and situation.
E. The frequency of patient hand-offs should be minimized w hen possible by creating caregiver schedules that
allow for continuity of care.
F. The patient and family w ill be aw are of or involved in hand-off w hen possible.
G. Documentation of hand-off communication w ill occur as appropriate by situation or setting or as required by
A. Hand-off tools should be used to standardize the content and process of the hand-off based on the type of
hand-off (see III.C.i-iv), setting and discipline involved. Technology such as Health Link may be used to
assist hand-off communication and documentation.
B. Each discipline is responsible for hand-off tool selection, caregiver education and competency assessment
of successful hand-off communications as required by the discipline
C. Hand-off communications should be part of the w ork expectations of caregivers and designed to f it into the
w orkflow of sending and receiving caregivers.
D. Suff icient time should be scheduled into the caregiver w ork schedule to allow for complete hand-off
preparations and communications.
E. Interdisciplinary hand-off communications are encouraged as a means to create shared situation aw areness
for patient care responsibilities.
F. Whenever possible, include the patient during hand-off communications to promote patient-centered care.
G. The hand-off should occur in a setting conducive for sharing information, i.e. in a quiet area that minimizes
Procedure – Hand-off Communication Specif ic Principles

Policy Title: Hand-Off Communication
Policy Number: 3.3.1

H. The sender synthesizes patient information from disparate sources for the hand-off communication
prior to passing it on to the receiver.
I. The sender provides details of patient’s history and status to the receiver, identifying and stressing
key patient information and critical elements.
J. An opportunity is provided for the receiver to clarify information and ask questions and for the
sender to have the receiver repeat back signif icant information.
K. The receiver accepts patient care responsibility from the sender.
L. The sender provides contact information to the receiver w hen possible in the event there are follow -
up questions.
M. Standardized w ritten or electronic patient information is provided by the sender to the receiver
w hen possible to supplement verbal hand-off communications.
N. Hand-off communications are documented as necessary or as appropriate to discipline.

Author(s): Director, Quality and Patient Safety
Senior Management Sponsor: VP, Quality and Patient Safety
Review ers: Nursing Executive Council; Operations Council; UW Health Safety Committee; UW Health
Quality Council; Resident Quality and Safety Council
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: June 15, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter New comer, MD
UW Health Chief Medical Officer

Christopher Green, MD
UW Health Associate Chief Medical Officer
UWHC Senior Vice President, Medical Affairs

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


Joint Commission Accreditation Standards for Hospitals, Home Care and Laboratories
American College of Graduate Medical Education Standards

Version: Revision
Next Revision Due: July 9, 2018
Formerly Know n as: Hospital Administrative policy # 8.88