What clinical handover documentation meets the Communicating for Safety Standard?

Documentation that shows a defined minimum content, a structured process, at least three approved identifiers, critical information passed to someone who can act, and notes written at the time. Those are Actions 6.05 to 6.11 of the Communicating for Safety Standard, and the RACGP asks the same of general practice.

What the standard asks

The Communicating for Safety Standard covers communication at every transition of care, when critical information emerges or changes, for correct identification and procedure matching, and in the healthcare record. It has 11 actions.¹

Behind them sits Action 1.16 of the Clinical Governance Standard, records available at the point of care, accurate and complete, secure and auditable.²

In general practice

The RACGP 5th edition, which practices are accredited against today, has a criterion for clinical handover, C5.3, in the Core module.³ The 6th edition carries the same ground into Transitions of care, CG5, in its Clinical governance standard.⁴

1. Define the minimum content. With your clinicians, write down what every handover must carry, for each type of transfer you make.
2. Fix your identifiers. Choose at least three approved identifiers and put them on every handover, transfer and discharge document.
3. Use one structure. Pick a structured format and use it every time, including the patient's goals and preferences.
4. Name the receiver. Record who accepted responsibility, and when, so accountability transfers with the patient.
5. Close the loop on critical results. Write down who must be told when a critical result arrives, how fast, and where that is recorded.
6. Audit five a month. Pull five handovers at random. Check the content, identifiers, signature and time. Fix what you find.

1. Patient name, date of birth, record number ______
2. From ______ To ______ Date and time ______
3. Reason for transfer ______
4. Diagnosis and current problems ______
5. Medicines, changes and allergies ______
6. Critical information, alerts and risks ______
7. Patient's goals and preferences ______
8. Follow-up required, by whom, by when ______
9. Signed by ______ Responsibility accepted by ______

Copy template

The guide to partnering with consumers evidence covers how patients take part in handover, and the guide to clinic AI in Sydney covers private facilities in New South Wales. The NSQHS and RACGP accreditation hub maps every standard.

Questions

How many patient identifiers does the NSQHS Standards require?

At least three approved identifiers, on registration and admission, when care is given, and on handover, transfer and discharge documents.

What must a clinical handover include?

The minimum information content your organisation defines with its clinicians, based on best-practice guidelines, plus the risks relevant to your service and the patient.

Does the RACGP require clinical handover documentation?

Yes. Criterion C5.3 Clinical handover in the 5th edition, and Transitions of care, CG5, in the 6th edition.

Sources

1. 1Australian Commission on Safety and Quality in Health Care, 2026Communicating for Safety StandardRead source
2. 2Australian Commission on Safety and Quality in Health Care, 2026Clinical Governance StandardRead source
3. 3RACGP, 2023Standards for general practices, 5th edition, table of contentsRead source
4. 4RACGP, 2026Standards for general practices (6th edition)Read source

Written by the wai team from Australian Commission on Safety and Quality in Health Care and the RACGP guidance, checked on 15 October 2026. This is guidance, not legal advice. Neither ACSQHC nor the RACGP endorses wai or any software.