FY1 · Clinical skills & reasoning
Documentation, handover and SBAR
Transferring information without losing it — a structured verbal handover, and notes that let the next person act.
Why this matters on day one
Most serious incidents involve a communication failure at a transfer of care. Handover is not administration; it is the point at which patients are most likely to be harmed, and structure demonstrably reduces that.
The sequence
- 1Escalate with SBAR. Situation, Background, Assessment, Recommendation — and the recommendation is not optional. Saying what you want is what turns a report into a request.
- 2Hand over by priority. Sickest first, not bed order. For each: who they are, what is wrong, what has been done, what is outstanding, what to watch for, and the resuscitation/ceilings-of-care status.
- 3Write notes that work. Date, time, your name, grade and legible signature. What you found, what you thought, what you did, what you are waiting for, and who you told. Document decisions AND the reasoning — "for CT tomorrow" is much less useful than "for CT tomorrow to exclude X; if Y worsens overnight, escalate to on-call surgeon".
- 4Document conversations. Discussions with families, capacity assessments, DNACPR decisions and refusals of treatment need contemporaneous notes. So do telephone advice and referrals — including the name of the person you spoke to.
- 5Close the loop. Explicitly hand over outstanding results. A blood test nobody chases is worse than one not taken, because it creates false reassurance.
SBAR — for the phone call you are about to make
S — "I'm the FY1 on ward 12. I'm calling about Mrs Ahmed, 74, in bed 6. She's hypotensive at 82/50 and I'm concerned."
B — "She was admitted three days ago with a community-acquired pneumonia, on IV co-amoxiclav. Background of COPD and CKD stage 3. Her NEWS2 has gone from 3 to 8 over four hours."
A — "She's peripherally cool with a capillary refill of 4 seconds, lactate 3.8, and she's only passed 90 mL in six hours. I think she's septic and under-filled — I've given 500 mL of Hartmann's and taken cultures."
R — "I'd like you to come and review her now, please. In the meantime, would you like me to give a further bolus and catheterise her?"
What goes wrong
- Giving Situation and Background and stopping — leaving the senior to extract the ask.
- Handing over by bed number, so the sickest patient is mentioned ninth.
- Not stating resuscitation status at handover.
- Notes that record actions but not reasoning, leaving the next person unable to judge whether the plan still applies.
- Verbal handover of an outstanding result with nothing written down.
Escalate when
- You cannot get hold of the person who needs to know → go up, and document that you tried.
- A handover you do not understand → ask at the time; the moment passes.
GMC Good Medical Practice 2024 · Academy of Medical Royal Colleges — Safe handover · RCP records standards