Professional-to-professional handover of care | Scottish Palliative Care Guidelines

Introduction

When caring for people with palliative care needs, it is essential that relevant clinical information is shared within and across care settings in a timely manner. This enables care professionals (working in and out of hours) to deliver person-centred care aligned to existing care plans, patient preference and disease trajectory.

Summary of information required for effective professional-to-professional handover

Diagnosis:

relevant medical diagnoses including any future treatment options, and
patient and carer understanding of diagnosis and prognosis.

Medications:

all current medications prescribed regularly and ‘as required’ including ‘just in case’ medication and oxygen, and
details of why medication has been started, stopped or amended while in hospital and recommended timeframes for medication review, such as if the patient is on steroids.
Confirm any verbal medication instruction or recommendation in writing electronically, such as by email.

Social Context:

Where relevant, include information on:

equipment in the home
formal and informal care provision
risks within the home environment that visiting health professionals need to be aware of (for example, pets), and
practical advice regarding entering the property, such as a key box with code number, or the presence of a locked medication box in the home.

See also the good practice guides Care for spiritual distress (existential crisis) and Social work in palliative care.

Future care planning:

Information, which may include:

wishes regarding medical treatment and care, future admissions to hospital or hospice (this may be referred to as a treatment escalation plan (TEP), a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) or, historically, often described as ’ceiling of care’)
preferences regarding preferred place of care and death
existence of documents such as a do not attempt cardiopulmonary resuscitation (DNACPR) form
power of attorney (and whether this relates to welfare and financial powers)
Adults with Incapacity (AWI) information
guardianship
clinical guidance on appropriate levels of treatment available to the personal in future.

For some people their spiritual or faith beliefs can mean that they have specific wishes for their care, either in life or for the care of their body in death. It may be important to enquire further, depending on the faith group and their personal wishes. See also Care for spiritual distress (existential crisis).

Professional handover from and within the Scottish community setting

Use of the Key Information Summary (KIS) and Emergency Care Summary (ECS)

In Scotland, the KIS allows clinical information from the GP electronic records to be shared across different parts of NHSScotland. Among the different components of the KIS are the ECS, current medical diagnoses, essential contacts, palliative care information, and KIS ‘Special Notes’.

The ’Special Notes’ is a free text section where non-read-coded notes can be entered. Other sections are automatically populated or involve tick boxes or short free-text fields.

When a KIS is completed, individual patient records are activated for sharing from within the GP clinical system, and users of other clinical systems and portals can view this information.

Practice points

An ECS is available for all patients (even where there is no KIS) and contains information about medicines and allergies.

The KIS is a shared electronic summary record enabling communication between care professionals within NHS Scotland.
Only GP practice staff can create and amend KISs. All other users have read-only access.
It is the GP practice’s responsibility to create or update an electronic KIS for the person as required.

A KIS contains key information, both formal and informal, that is important to a patient and relevant to their treatment and care.
The KIS ‘Special Notes’ section should be used to add additional information, such as indicating palliative care involvement and care plan, and the existence of other key documents such as a future care plan, power of attorney and guardianship.
If any community-based health or social care professional becomes aware of a change in a person's preferences for future care, they should take responsibility for contacting the GP practice to request an update to the KIS.

Important: Since October 2023, explicit consent is no longer required for the creation or sharing of a KIS. The legal basis for processing is established under data protection law for the provision of direct care. This was confirmed in a letter from the Scottish Government to health boards and others.

The KIS can be viewed by staff from: NHS 24; GP Out-of-Hours (OOH) services; Scottish Ambulance Service (SAS); secondary care (including, hospital emergency departments or admissions units); other community health and social care services (including third sector hospices).

Special Notes section

The KIS Special Notes section should include key information that is important to the person, such as:

their needs or wishes related to end-of-life care, their social, emotional, psychological, communication, spiritual, cultural and religious practices
whether there is a need to expedite the issuing of a death certificate, along with relevant details of how this is to be done.

Refer to local policies.

Note: See also good practice guide Care for spiritual distress (existential crisis)

Future care planning documents (previously referred to as an ‘Anticipatory Care Plan’ or ‘ACP’) are not visible to all out-of-hours providers unless the details are also added in the Special Notes section of the KIS.

If a patient has any of the documents listed below, it is important to note what has been discussed or decided. Where these documents are in place these should be indicated either by tick box or free text depending on local systems:

do not attempt cardiopulmonary resuscitation (DNACPR)
recommended summary plan for emergency care and treatment (ReSPECT)
children and young people acute deterioration management (CYPADM)
power of attorney or guardianship (POA)
Adults with Incapacity (AWI) documentation, and
other future care planning documentation.

If a professional involved in a person's care does not have the systems access required to routinely review clinical notes, other professionals involved in the person’s care should make reasonable efforts to share the most important information by other secure means, such as the KIS.

Note that (as of May 2026) when a patient has a ReSPECT document in place, this can be viewed by GP OOH and SAS clinical hub services via the ReSPECT tab in Adastra. (Adastra is the national clinical patient management system used for OOH, urgent and unscheduled care.)

Additional Information that the KIS should contain

If the KIS has been shared, information extracted from GP records that might be relevant includes:

Patient and carer details
Patient’s own GP and nurse
Patient medical condition:
- main diagnosis
- other relevant issues.
Current care arrangements
- syringe pump at home (see syringe pump/driver guidelines)
- catheter and continence products at home
- moving and handling equipment at home.
Patient and carer awareness of the condition:
- understanding of diagnosis and prognosis.

Advice for out-of-hours care:
- agreed care plan
- preferred place of care
- should GP be contacted out of hours? (if yes, contact details)
- resuscitation status agreed (if yes, status)
- whether a GP will sign the death certificate in normal circumstances
- additional useful out-of-hours information.

Medication information out of hours in Scotland

Emergency care summary

The ECS is available for all patients, even if a KIS has not been released and provides information on medications, including:

allergies and drug reactions
current drugs and doses
additional drugs available at home, including injectable medication, and
date of issue of prescriptions.

Important: clarify what medications are in the home and what doses are being administered.

The dose recorded on the ECS reflects the dose at the time of issue via the GP computer system. This may differ from the dose now in use. Doses of subcutaneous medications can be obtained from the community drug administration chart.

Additional medication may be in the home if issued using paper prescription pads, such as by an OOH district nurse prescriber, for example.

Other notes systems in use in Scotland

Many district nursing teams use separate notes systems, such as the multidisciplinary information system (MiDIS) or Morse community electronic patient record system to document key information or alerts. These systems do not automatically populate or replace the KIS, and it remains important that a person's preferences for future care are highlighted and up to date within the KIS as well.

Out-of-hours handover arrangements for high-risk patients

Some patients will be at a high risk of requiring out-of-hours GP, ambulance or nursing services. This may be because of severe distress or crisis events, such as catastrophic bleeding, loss of airway or seizure. Where healthcare professionals recognise this, it is good practice to ensure direct handover processes are in place. This may be calling to speak with the duty healthcare professional or sending a direct email outlining the immediate issues.

Professional handover on discharge from hospice or hospital

Immediate discharge letter (IDL)

When a patient is discharged from secondary care to a community setting, an IDL, or similar written handover document, should be shared promptly with the person's GP and, where appropriate, with the person.

On occasion, it may be decided that an IDL should not be given to the person directly. This could be because of a lack of capacity or risk of unacceptable psychological harm. In such circumstances, consider sharing the IDL with someone who has the patient’s consent to be involved in their care. This could be the next of kin or someone with legally appointed guardianship or welfare power of attorney.

Additional handover considerations on discharge from hospice or hospital

When patients are urgently discharged from secondary care to the community for care in the last hours or days of life, please refer to the guideline on rapid transfer home in the last days of life.

Consider contacting the GP surgery to alert them to the planned discharge in advance. It may be helpful to highlight key information within the IDL and discuss any content relevant to completing an electronic palliative care summary (ePCS)/KIS and for the GP to share the KIS. [see sections on KIS and IDL]. Request for the patient to be added to their palliative care register and for the ePCS/KIS to be updated.
When issuing ’just in case’ medication, supply a diluent, such as water for injection, and the accompanying community drug kardex to ensure safe administration.

If a person has specific or anticipated nursing needs, there should be a direct nursing handover to district nursing and other community nursing teams.

Inform district nursing and other community nursing teams if a patient is being discharged home in the last days of life, and whether they have a supply of ‘just in case’ medications.

Ensure an adequate supply of current medication is provided on discharge

Share any information that visiting health professionals need to be aware of when visiting the home, such as details of any risks within the home environment, key code number for door presence of a locked medication box.