Safe Shift-to-Shift Handover in Residential Long-Term Care for Older People in Viet Nam: Critical Information, Outstanding Tasks and Clear Accountability

Safe Shift-to-Shift Handover in Residential Long-Term Care for Older People in Viet Nam: Critical Information, Outstanding Tasks and Clear Accountability

A caregiver finishes an afternoon shift at a residential long-term care facility. Earlier in the day, an older resident needed additional assistance with mobility, but the activity was postponed because staff were attending to other residents. The caregiver records a brief note before leaving. When the evening team begins work, the incoming staff members are unaware that the assistance remains outstanding.

In another situation, a resident's family informs a staff member about a change in the person's usual routine. The information is written in a communication book but is not discussed during the next shift handover. The following team continues with the established arrangements, unaware that an important preference has changed.

Neither situation necessarily reflects a lack of knowledge or commitment. The problem lies in how information and responsibility move between people working at different times.

These examples illustrate an important distinction: recording information, communicating information and ensuring that necessary action continues are not the same thing.

Residential long-term care depends on continuity. Older people may receive assistance throughout the day and night from different caregivers, nurses, supervisors and other personnel. Although staff members change, residents' needs, preferences and unfinished care activities do not disappear when a shift ends.

An effective handover should therefore do more than describe what happened during the previous working period. It should help the incoming team understand what matters now, which activities remain unfinished, who is responsible for the next steps and when further action or escalation is necessary.

For residential long-term care organizations in Viet Nam, the central question is how to ensure that critical information, outstanding care tasks and responsibility are transferred reliably between shifts without creating unnecessary documentation or gaps in care.

Why Shift Handover Matters in Residential Long-Term Care

Shift changes are a routine part of residential care. Depending on the facility's operating model, personnel may work during the day, evening, night, weekends or other scheduled periods. Residents remain in the same environment, but the people responsible for supporting them change.

This creates a recurring point at which important information can be lost, misunderstood or transferred without anyone being clearly responsible for acting on it.

A resident's needs may have changed during the previous shift. A planned activity may remain incomplete. A family member may have raised a concern requiring follow-up. Equipment may be unavailable, or an arrangement supporting a resident may need further review. If the incoming team does not receive this information, it may continue with routines that no longer reflect the person's circumstances.

The problem is not necessarily that the care plan is missing. A plan may have been appropriate when prepared but may not capture every recent development requiring attention during the next several hours. Similarly, a care record may contain extensive information without making important changes or unfinished activities sufficiently visible.

Handover connects established care arrangements with what happened during the preceding shift and what still needs to be done.

This matters particularly for older residents whose everyday activities depend on assistance from others. An overlooked request or unfinished activity may cause unnecessary waiting, discomfort or disruption when the person cannot complete it independently.

However, not every communication failure results in harm, and not every unfinished activity represents a safety incident. The significance depends on the resident's needs, the nature of the activity, the consequences of delay and the support available.

A reliable handover process should help staff recognize these differences rather than treat every item as equally urgent.

Timing is also important. Information indicating an immediate safety concern or a need for urgent professional assessment should be escalated when it becomes known. It should not be held until the next routine shift handover.

Handover supports continuity, but it must never become a reason to delay necessary action.

Documentation, Communication and Transfer of Responsibility

Residential care facilities may use daily notes, communication books, care plans, task records or electronic systems to document assistance and relevant events.

These records support continuity, but they serve different purposes.

A care plan describes the agreed assistance intended to meet a resident's ongoing needs and preferences. Daily records document relevant observations, activities and events. Shift handover connects that information with the immediate responsibilities of the incoming team.

A record may show that assistance was postponed. The handover should establish whether the activity remains necessary and what should happen next. A note may document that a resident's routine has changed. The handover should ensure that the incoming team understands the change and whether the assistance provided needs to be adjusted.

The distinction becomes particularly important when work remains unfinished.

If an outgoing caregiver records that a task was not completed, the information has been documented. If the caregiver mentions it to another employee, it has been communicated. Continuity still depends on whether the appropriate receiving person understands the task, its priority and the action expected within their assigned responsibilities.

A handover should not be considered operationally complete simply because a message has been sent or a form has been signed.

Receiving personnel should have an opportunity to confirm their understanding, clarify uncertainties and identify responsibilities they cannot appropriately undertake.

This principle is consistent with the Agency for Healthcare Research and Quality's TeamSTEPPS approach, which describes handoff as the transfer of information together with responsibility and accountability.

TeamSTEPPS was developed primarily for healthcare teams. Its communication principles can inform residential long-term care, but they do not establish a mandatory handover procedure for every residential care facility in Viet Nam.

The distinction between transferring responsibility and completing work also deserves attention.

A handover may be appropriately completed while a task remains outstanding, provided the next action, responsible person and necessary arrangements are clear. However, transferring a task to another employee does not mean that the task itself has been completed.

An unresolved activity should remain visible until it has been performed, appropriately canceled following a justified decision or otherwise resolved through an appropriate process. Reassignment changes who is responsible for the next step; it does not automatically resolve the underlying need.

This prevents organizations from confusing successful communication with successful delivery of care.

It is also important to distinguish an employee's assigned responsibilities from the continuing obligations of the care provider. Transferring an operational task between shifts does not automatically remove the organization's responsibilities under applicable law or service arrangements.

The Legal and Operational Context in Viet Nam

Residential long-term care services in Viet Nam operate through different legal and organizational arrangements.

Some facilities belong to the social assistance system. Others operate through nonpublic service models, while certain organizations combine personal care with services delivered by external healthcare professionals or licensed healthcare establishments.

The requirements applicable to these organizations are not necessarily identical.

The Law on the Elderly No. 39/2009/QH12, as amended, provides an important foundation concerning older people's rights, care and support. The law establishes relevant rights and responsibilities, while the specific operating obligations of residential care providers depend on their legal status, functions, applicable regulations and service arrangements.

A recent development is Decree No. 395/2026/ND-CP, issued on October 23, 2026, concerning the operation and management of social assistance facilities.

The decree is scheduled to take effect on December 7, 2026.

It establishes provisions for specified categories of social assistance facilities, including certain facilities providing care and support for older people.

Article 6 identifies tasks that facilities may undertake, in part or in full, according to their functions, type, service population and applicable legal requirements. These include assessing needs, preparing and reviewing intervention and assistance plans, managing cases, providing care and protection, and coordinating with relevant services.

These activities provide a relevant regulatory context for organizing continuous support.

However, Decree No. 395/2026/ND-CP should not be interpreted as establishing one mandatory shift-handover form or an identical handover procedure for every residential long-term care facility in Viet Nam.

Its applicability must be determined according to each organization's legal classification and actual activities. Facilities should also consider other applicable establishment, operating, professional and recordkeeping requirements rather than assuming that the new decree replaces all existing obligations.

Where a residential organization provides regulated medical examination and treatment services, the Law on Medical Examination and Treatment No. 15/2023/QH15, as amended, and its applicable implementing regulations must also be considered.

Clinical activities remain within the lawful responsibilities and professional scope of appropriately authorized healthcare personnel and organizations.

The handover of clinical responsibilities may require more specific information, verification and procedures than the transfer of routine personal-care tasks. These activities should be coordinated where necessary without treating them as interchangeable.

Personal information represents another important responsibility.

The Law on Personal Data Protection No. 91/2025/QH15 and Decree No. 356/2025/ND-CP, both effective January 1, 2026, establish the current general framework for personal data protection.

Shift handovers may involve residents' personal circumstances, support needs, health-related information, family contacts and daily activities. Organizations must ensure that collecting, using, sharing, storing and retaining such information complies with applicable requirements.

For facilities in Viet Nam, the practical challenge is to establish handover arrangements that support continuous care while remaining consistent with their lawful functions, personnel responsibilities and information-management obligations.

The operational methods proposed in this article are additional quality improvement approaches. They are not independently established statutory requirements.

What International Guidance Can Contribute

International guidance offers useful lessons about communicating important information and maintaining accountability between care workers.

Australia's Strengthened Aged Care Quality Standards, which took effect under the Aged Care Act 2024 framework on November 1, 2025, include Outcome 3.3, Communicating for Safety and Quality.

This outcome requires effective communication of critical information relevant to care and services, including communication between aged care workers and with older people, their supporters and relevant healthcare professionals. It also addresses the appropriate communication and escalation of risks, changes and deterioration in a person's condition.

These requirements provide an important reference for organizations considering how relevant information reaches those responsible for delivering care.

The National Institute for Health and Care Excellence (NICE) provides another example through guideline SC1, Managing Medicines in Care Homes.

Recommendation 1.3.7 advises care home providers to establish a process within their medicines policy for recording the transfer of information about residents' medicines during shift handovers and when residents move between care settings.

This recommendation concerns medicines information specifically. It should not be interpreted as establishing a complete general handover protocol for every care activity.

The Agency for Healthcare Research and Quality's TeamSTEPPS 3.0 resources emphasize clear information exchange, transfer of responsibility and accountability, acknowledgment by the receiving person and opportunities to resolve uncertainty during handoff.

The Australian Commission on Safety and Quality in Health Care's Communicating for Safety Standard also provides relevant principles concerning structured clinical handover, communication of critical information and transfer of professional responsibility.

These healthcare-focused approaches require appropriate adaptation before being applied to nonclinical residential care activities.

The World Health Organization's 2007 Patient Safety Solution: Communication During Patient Handovers highlights the risks associated with communication gaps when responsibility for patient care changes.

WHO Europe's 2024 publication, Promoting Quality Management in Long-Term Care: Principles, Key Components and Directions for Policy Action, provides broader guidance on organizational learning, quality management and continuous improvement.

These sources come from different healthcare and long-term care systems. Their legal obligations, professional requirements and intended applications are not interchangeable.

For HLVN, their value lies in several shared principles: information should be relevant and current, responsibilities should be clear, receiving personnel should be able to clarify uncertainties, and the effectiveness of handover should be examined through what happens afterward.

The objective is not to introduce a foreign handover system unchanged into Vietnamese residential care. It is to use relevant evidence and experience to improve local operational reliability.

A Shift Handover Reliability Pathway

A reliable handover should connect the end of one working period with the beginning of another without allowing important needs or responsibilities to become unclear.

The proposed Shift Handover Reliability Pathway brings together six activities: preparing current information, identifying critical changes, making outstanding tasks visible, confirming receipt and responsibility, completing or escalating necessary actions, and reviewing handover effectiveness.

Preparation begins before the shift changes. Outgoing personnel should ensure that relevant activities, observations and developments have been accurately documented.

The next step is to identify information requiring the incoming team's attention. This may involve significant changes in a resident's support needs, unresolved concerns, altered preferences or matters requiring follow-up.

Outstanding activities should be distinguished from those already completed, appropriately rescheduled or canceled.

During handover, receiving personnel should be able to clarify the information, understand priorities and identify responsibilities that cannot be undertaken within their role or available resources.

Afterward, the relevant activities should be completed, appropriately reassigned or escalated through the facility's established arrangements. Outstanding matters should remain open until an appropriate resolution has been confirmed.

Management should periodically examine whether this process works during ordinary operations and whether recurring gaps require improvement.

The pathway should not be used to delay urgent action. Matters requiring immediate attention must be communicated and escalated when identified, regardless of the next scheduled handover.

This proposed framework is intended to support operational quality improvement. It is not a statutory handover protocol, clinical authorization procedure or certification standard.

Identifying the Information That Matters Most

An effective handover does not require every detail of a resident's history to be repeated whenever staff change shifts.

Too much information can make important matters difficult to identify.

The purpose is to provide incoming personnel with what they need to continue the agreed assistance safely and appropriately.

For some residents, there may have been no significant change during the previous working period. A brief confirmation that established arrangements continue may be sufficient, provided authorized personnel can access the relevant records.

For others, a new development may require direct communication.

A resident may need more assistance with an activity that was previously performed independently. The person may have requested a change in routine. A planned service may remain incomplete, or a concern may be awaiting a response from another employee or provider.

The incoming team needs to understand what has changed, what remains uncertain and what action is expected.

Information should be specific enough to guide work without including unnecessary personal details.

For example, describing a resident as difficult during the afternoon provides little useful information and may introduce an unfair judgment. A more helpful handover describes the actual observation, such as the resident declining an activity, the circumstances in which this occurred and whether any assistance or review remains necessary.

Staff should distinguish what they observed from what another person reported and from their own interpretation.

This distinction matters when the reason for a change remains uncertain.

A caregiver may notice that a resident needs more assistance than usual without knowing why. The handover should communicate the observation and clarify whether appropriate professional assessment or follow-up has been arranged.

The employee should not be expected to make a medical diagnosis, and the receiving team should not treat an unsupported assumption as an established fact.

Where a resident has several matters requiring attention, information may need to be prioritized according to its importance, timing and the responsibilities of the receiving personnel.

An unresolved safety concern should be easy to distinguish from a routine administrative reminder. A time-sensitive activity should not become buried among details that can be reviewed later.

The goal is to communicate information that helps the next team provide appropriate support, not reproduce the entire care record.

Making Outstanding Care Tasks Visible

One of the most valuable functions of shift handover is ensuring that unfinished activities remain visible until an appropriate next step has been established.

A task may remain incomplete for many reasons.

A resident may have declined assistance. Personnel may have been responding to another priority. Necessary equipment may have been unavailable, or an external service may not yet have responded. Sometimes a task cannot be completed because additional professional guidance is required.

The reason should be recorded accurately, but the most important question is what needs to happen next.

An unfinished activity should not automatically be transferred to another shift without considering whether it remains necessary, whether delay is appropriate and who can undertake it.

For example, an activity postponed at the resident's request may be rescheduled according to the agreed care arrangements.

Another activity may require attention within a particular period because further delay would leave an essential support need unmet.

A different matter may require a supervisor or authorized healthcare professional rather than a general caregiver.

These situations should not be treated alike.

Where an outstanding task remains relevant, the handover should establish the expected next action, its priority, the person or role responsible and any necessary timeframe or escalation.

An activity already completed should be clearly distinguished from one awaiting action.

Similarly, a concern referred to another person is not necessarily resolved simply because the referral was sent. The organization should determine whether acknowledgment, a response or confirmation of completion is required.

Unfinished care should have a visible next step and an identifiable person responsible for coordinating that step.

This is particularly important for tasks repeatedly carried forward between shifts.

An activity should not remain in a communication book for several days without anyone understanding why it has not been completed.

Repeated deferral may indicate a scheduling problem, unclear responsibility, insufficient resources or a limitation in the facility's ability to deliver the agreed service.

Management should also consider whether a repeatedly postponed task remains appropriate under the current care arrangements. Circumstances may have changed, and the activity may need to be reviewed rather than indefinitely transferred between workers.

The solution may require a management decision, reassessment of service arrangements or external professional input rather than another reminder during handover.

The important distinction is between postponement, reassignment and resolution. Postponement changes when work is expected. Reassignment changes who is responsible. Neither necessarily means that the resident's need has been met.

A reliable handover system should preserve that distinction.

Establishing Clear Responsibility at the Shift Boundary

Handover can fail even when the information itself is accurate.

An outgoing employee may believe that a task has been transferred because it was mentioned during a conversation. The incoming employee may interpret the information as background rather than an activity requiring action.

A task may also be discussed in front of several workers without anyone being identified as responsible.

These situations create gaps in accountability.

Facilities should establish who receives the handover, how tasks are assigned and how uncertainties are resolved.

Receiving personnel should understand the responsibilities expected within their role.

Where several employees share responsibilities, the handover should distinguish general team awareness from specific task ownership.

For example, the incoming team may need to know that a resident requires assistance during the evening. However, someone must also know who will organize or provide that assistance under the facility's staffing arrangements.

Responsibility should not depend on the assumption that any available worker will eventually act.

Acknowledgment by receiving personnel and an opportunity to clarify questions can help prevent misunderstandings.

For important outstanding work, it may be useful for the receiving person to confirm the next action in their own words. This is particularly relevant when the task is unfamiliar, involves several steps or requires follow-up with another person.

However, confirming responsibility should not be interpreted as requiring outgoing employees to remain indefinitely at work when an incoming team or appropriate replacement arrangement is unavailable.

The organization remains responsible for managing staffing coverage, working hours and continuity in accordance with applicable employment, service and contractual obligations.

If the receiving team lacks the personnel, competence or authority needed for an assigned task, the matter should be escalated to an appropriate supervisor or manager.

A handover cannot make an unsuitable assignment appropriate merely by documenting it.

Management must ensure that important activities are supported by workable arrangements and that problems exceeding the receiving team's capabilities are addressed through the appropriate process.

Designing Handover Around Actual Facility Operations

There is no single handover format suitable for every residential long-term care organization.

Facilities differ in size, staffing arrangements, service scope, resident needs and available technology.

A small residential service may use direct communication between outgoing and incoming personnel supported by a concise record. A larger organization may require a team-level handover followed by more specific communication between staff responsible for particular residents or service areas.

The format should reflect how care is actually organized.

Handover should occur at a predictable point in the staffing schedule and allow sufficient time for matters requiring attention. It should also be supported by reliable records so that continuity does not depend entirely on individual memory.

However, a lengthy handover is not necessarily a better handover.

If staff spend too much time repeating routine information, critical changes and unfinished activities may receive insufficient attention.

Organizations should distinguish information available in the care record from information requiring direct communication.

Where appropriate, a structured verbal exchange can help clarify important matters. Written or electronic records can provide continuity and allow personnel to check details when necessary.

Neither method should automatically replace the other.

A digital handover system may help staff working across different areas, but it does not establish that a message has been understood simply because it was entered into the system.

Similarly, a verbal conversation may be useful but difficult to verify when significant responsibilities remain undocumented.

The organization should choose arrangements that personnel can use consistently under normal operating conditions.

The location of handover also deserves consideration. Staff need an environment where they can communicate appropriately without unnecessary interruptions or exposing residents' private information to people who do not need it.

Handover should remain possible during unexpected staffing changes. An employee may become unavailable, or a shift may need coverage from someone unfamiliar with the residents.

The facility should have an appropriate alternative process rather than allowing handover to depend entirely on one individual.

The objective is a practical and dependable method, not a complex administrative exercise.

Managing Day, Evening and Night Shift Differences

The information needed during handover may change according to the responsibilities of the incoming shift.

A morning team may need to understand whether overnight events have affected a resident's usual activities or support needs.

An evening team may need information about outstanding daytime tasks, changes in personal preferences or matters requiring follow-up before the night shift.

Night personnel may need to know which assistance is expected, what concerns remain unresolved and how to obtain help when fewer staff or external services are available.

These differences should influence the content of handover without requiring entirely separate systems.

The essential structure can remain consistent while the information reflects the responsibilities of each working period.

A particular problem may require different arrangements depending on when it occurs.

For example, a piece of essential equipment that becomes unavailable during the day may be addressed through routine maintenance. If the same problem occurs at night, staff may need a suitable interim arrangement and a clear process for obtaining assistance.

The handover should therefore consider whether the incoming team can carry out the assigned actions under the conditions of that shift.

Assigning a task to personnel who are unavailable or not authorized to undertake it does not establish reliable continuity.

Night, weekend and holiday arrangements deserve attention because access to managers, external providers and specialized personnel may differ from ordinary daytime operations.

Facilities should understand how unresolved matters will be managed when the responsible person or service is not immediately available.

The purpose is not to create a separate handover system for every shift. It is to ensure that the information communicated is relevant to the work that can and must be performed during the next operating period.

Distinguishing Routine Care Handover From Clinical Handover

Residential long-term care may involve personnel with different professional responsibilities.

General caregivers may assist with mobility, personal hygiene, meals, activities and other everyday needs. Nurses and other authorized healthcare professionals may undertake clinical activities where the organization is legally permitted to provide those services.

These responsibilities should not be confused.

A routine care handover may communicate that a resident has requested additional assistance, that an activity remains incomplete or that an established preference has changed.

A clinical handover may involve professional observations, assessments, treatment instructions and clinical decisions requiring specific competencies.

The two processes may need to exchange relevant information, but their purposes and responsibilities remain distinct.

For example, a general caregiver may observe that a resident's usual abilities have changed. The employee should communicate that observation and follow the facility's appropriate escalation process. They should not be expected to diagnose the cause or make unauthorized clinical decisions during handover.

Medication-related information deserves particular attention.

NICE guideline SC1 specifically addresses the transfer of medicines information during shift handovers in care homes.

For organizations in Viet Nam, medication-related handover should remain consistent with the facility's lawful service scope, applicable professional responsibilities and established clinical procedures.

Nonclinical personnel should not independently interpret medication changes, modify prescribed treatment or assume clinical responsibilities simply because a task appears in a general handover record.

Where a clinical matter remains unresolved, the relevant information should reach the appropriately authorized professional or service responsible for the next step.

Issues requiring immediate medical attention should be escalated promptly rather than deferred until the next routine shift.

The organization should also avoid using general handover records as substitutes for medication administration records, clinical documentation or other legally or professionally required records.

This distinction helps maintain continuity while protecting professional boundaries.

Keeping Residents' Preferences Visible Between Shifts

A handover focused exclusively on tasks and risks may overlook information important to the person receiving care.

Residents have preferences about daily routines, communication, activities and the way assistance is provided. Those preferences may change, sometimes during a single day.

Someone may request help with an activity later than usual. Another resident may prefer assistance from a familiar caregiver when available. A person may decline an activity and wish to reconsider it at another time.

These matters can be important to the experience of living in a residential facility.

The incoming team should receive relevant updates without assuming that every preference requires a lengthy written explanation.

Staff should also distinguish the resident's expressed wishes from their own interpretations.

For example, a person who declines assistance should not automatically be described as uncooperative.

It is more useful to communicate what the resident said or did, the circumstances involved and whether further discussion or support is needed.

Where residents can participate in relevant communication, facilities should respect their involvement and preferences.

This does not mean that every resident must attend a staff handover meeting. Rather, organizations should ensure that important changes in residents' wishes can reach the personnel responsible for providing assistance.

Families may also provide useful information when their involvement is appropriate and consistent with the resident's rights.

However, family communication should not automatically replace the resident's own participation or become a reason to disclose unnecessary personal information.

A person's preferences should not be lost merely because different staff members provide assistance at different times.

Person-centered handover helps preserve continuity not only of tasks, but also of how residents experience their care.

Handling Incomplete or Conflicting Information

Information available during handover is not always complete.

An employee may be uncertain whether an activity was performed. Two records may contain conflicting details. A resident may describe an event differently from the employee who documented it.

These situations should be handled carefully.

The receiving team should not be encouraged to make assumptions merely to finish the handover quickly.

Where information is uncertain, that uncertainty should be communicated clearly.

The responsible personnel should determine whether further verification, observation or professional assessment is necessary.

For example, an outgoing employee may be unable to confirm whether a task assigned to another staff member was completed.

The handover should identify that uncertainty rather than record the task as completed without evidence.

The next step may involve contacting the responsible person, reviewing available records or arranging appropriate follow-up.

Where the uncertainty concerns an essential activity that cannot reasonably wait, escalation may be necessary while clarification is being sought.

Records should distinguish observed facts, reported information, actions already taken and matters awaiting confirmation.

This reduces the likelihood that an assumption made during one shift becomes an accepted fact in subsequent shifts.

Where different accounts exist, staff should avoid assigning blame or drawing unsupported conclusions before the relevant information has been reviewed.

The aim is not to eliminate every uncertainty. It is to prevent uncertainty from being hidden or passed along without an appropriate next step.

Protecting Privacy During Handover

Shift handovers may involve sensitive personal information.

Residents' support needs, family circumstances, health-related information and everyday activities should not be discussed indiscriminately.

Facilities should consider where handovers take place, who participates and which information receiving personnel genuinely need.

Discussing a resident's private circumstances in a public corridor or shared dining area may expose information to people who have no legitimate reason to receive it.

Similarly, sharing identifiable resident information through informal messaging groups or personal devices may create privacy and security concerns.

The Law on Personal Data Protection No. 91/2025/QH15 and Decree No. 356/2025/ND-CP establish relevant requirements for personal data processing.

Organizations should consider the lawful basis, purpose, necessity, access controls, security measures, retention and other applicable obligations when using paper or electronic handover systems.

Health-related information may require particular safeguards.

A caregiver may need to know how to provide agreed assistance appropriately without requiring access to the resident's entire medical history.

A supervisor or authorized healthcare professional may need additional information for a specific responsibility.

The facility should ensure that personnel receive information appropriate to their lawful duties.

Handover records should also be stored, accessed and retained according to applicable requirements.

Where staff use electronic systems, access rights and account management should reflect their responsibilities. Where paper records are used, organizations should ensure that information is not left openly accessible to unauthorized individuals.

Privacy must not be used as a reason to prevent lawful communication necessary for safe care. Equally, operational convenience does not justify unnecessary disclosure.

A reliable handover provides relevant information to the appropriate people through suitable channels.

Managing Unplanned Staffing Changes

Staffing changes can make handover more difficult.

An incoming employee may be unfamiliar with the residents. A replacement worker may be assigned at short notice. A supervisor may need to cover responsibilities normally performed by another person.

These circumstances should be anticipated where reasonably possible.

A worker unfamiliar with the facility may require additional information, but handover should not become a substitute for necessary orientation, training or competency preparation.

Current care information should remain accessible to authorized personnel in a form they can understand.

Handover should draw attention to critical changes and immediate responsibilities rather than attempt to repeat every detail verbally.

A replacement employee should not be assigned work beyond their competence or authority simply because it was included in the handover.

Where additional supervision or professional support is necessary, the facility should arrange it appropriately.

The same principle applies when responsibilities change during a shift.

A task may need to be transferred because the originally assigned employee becomes unavailable. The new arrangement should clarify who is responsible and whether the priority or expected timing has changed.

Where a replacement worker does not know the residents, management should consider whether additional preparation is needed before assigning important activities.

Repeated handover difficulties caused by staffing shortages, insufficient preparation or unclear job roles should be addressed by management.

They should not be treated solely as failures of individual communication.

Responding When Handover Fails

Even well-designed handover arrangements can fail.

A task may be omitted from the record. An incoming employee may misunderstand the expected action. A message may not reach the appropriate person, or responsibility may remain unclear.

The facility should have a way to identify and respond to these situations.

When an important omission is discovered, the first concern is whether a resident needs assistance or whether an unresolved matter requires prompt attention.

The response should reflect the circumstances and the facility's capabilities.

If there is a suspected medical emergency, personnel should follow the appropriate emergency procedures rather than relying on ordinary handover correction.

Where the issue can be managed operationally, the responsible personnel should clarify the outstanding task and establish a suitable next step.

The organization should also consider whether the communication failure may have affected other residents.

For example, if the incoming team did not receive an updated task record, several residents may have outstanding activities requiring review.

After immediate concerns have been addressed, management should examine why the failure occurred.

The cause may involve insufficient handover time, unclear responsibilities, inconsistent records, excessive information or unavailable personnel.

An individual error may be involved, but an effective review should not automatically assume that every failure results from carelessness.

Corrective actions should address the conditions contributing to the problem.

A reminder to communicate better may have limited value if the facility continues to use a confusing handover method or regularly changes staffing without workable coverage arrangements.

Where a failure involves possible neglect, significant harm or another matter requiring formal reporting or professional intervention, the organization must follow the applicable legal and organizational processes. Such matters should not be managed solely as routine communication improvement.

The purpose is to improve reliability and accountability while ensuring that serious concerns receive the attention they require.

Three Practical Tools for Implementation

Residential long-term care organizations can strengthen handover through three complementary tools: a Shift Handover Minimum Information Set, an Outstanding Care Tasks and Follow-Up Register, and a Shift Handover Reliability Review.

Together, these tools help facilities identify the information that matters, maintain visibility of unfinished work and verify whether the process functions as intended.

They are proposed organizational quality improvement resources. They are not statutory handover forms, clinical protocols, official regulatory assessment instruments, accreditation requirements or certification schemes.

Shift Handover Minimum Information Set

The Shift Handover Minimum Information Set helps facilities identify the information incoming personnel need to continue the agreed assistance.

It should be adapted to the organization's functions, staff roles and resident population.

Relevant information may include identification of the resident, significant developments during the preceding shift, changes affecting everyday support, unfinished activities, relevant preferences and matters requiring professional or management follow-up.

Where necessary, the information should identify the expected next action, responsible person or role, timeframe and any unresolved uncertainty.

The information set should be concise enough for consistent use.

It should not require staff to repeat an entire care plan or personal history at every shift change.

Where details are already available in the authorized care record, the handover can refer to that source while highlighting changes and activities requiring attention.

Facilities should also ensure that personnel can identify the correct resident, especially where people have similar names or share accommodation areas.

Room location alone may not provide sufficient certainty in situations where confusion is possible.

The tool should allow uncertainty to be recorded instead of encouraging incomplete information to be presented as confirmed.

It should also distinguish matters requiring immediate action from those that can appropriately be addressed during the next shift.

The information set should be reviewed when the facility changes its services or identifies recurring communication problems.

Its purpose is to make important information easy to recognize and use without generating unnecessary paperwork.

Outstanding Care Tasks and Follow-Up Register

The Outstanding Care Tasks and Follow-Up Register addresses the risk that unfinished activities will be repeatedly passed between shifts without clear ownership.

The register should identify the activity requiring follow-up, why it remains outstanding, the next action, its priority and the responsible person or role.

Where timing matters, the expected timeframe should be clear.

For example, a resident's requested activity may have been postponed, equipment may require attention or an external response may still be awaited.

The register should distinguish activities that can appropriately be rescheduled from those requiring prompt action or professional escalation.

It should also identify matters that have been referred but remain unresolved.

Assigning a task does not necessarily mean that the receiving person has sufficient resources, competence or authority to complete it.

Where this is uncertain, the matter should be escalated rather than treated as successfully transferred.

Personnel should be able to confirm completion, document an appropriate alternative arrangement or explain why further action remains necessary.

The register should distinguish acknowledgment of responsibility from actual resolution of the outstanding matter.

Repeatedly carried-forward tasks deserve management attention.

An activity appearing across several consecutive handovers may indicate insufficient resources, unclear responsibilities or an unrealistic service arrangement.

The register should support coordination rather than become a growing list of unresolved matters.

Its value lies in making unfinished work visible and ensuring that important actions reach an appropriate conclusion.

Shift Handover Reliability Review

The Shift Handover Reliability Review examines whether the organization's handover process works during ordinary operations.

It may involve observing selected handovers, reviewing records, discussing experiences with staff and examining situations where information or tasks were not transferred effectively.

The review should consider whether critical information was communicated, whether receiving personnel could clarify uncertainties and whether important outstanding tasks had clear responsibility.

It should also examine what happened after the handover.

Were transferred activities completed? Were they appropriately reassigned or escalated? Did any issue remain unresolved without a clear reason?

A handover record may appear complete while important work remains unfinished.

For this reason, the review should go beyond checking whether forms have been signed.

The facility may examine a sample of tasks carried forward between shifts and determine whether the documented follow-up actually occurred.

Where gaps are found, management should consider whether improvements are needed in scheduling, recordkeeping, staff preparation or supervision.

Staff feedback may also identify practical problems, such as handover arrangements being consistently interrupted or essential information being difficult to locate.

The aim is to verify that handover supports continuity in practice, not merely that personnel follow an administrative routine.

Measuring Reliability Without Creating Misleading Indicators

A facility may report that every shift handover was completed because all required forms were signed.

That measure provides limited information about whether critical tasks were understood and acted upon.

A more meaningful assessment considers both information transfer and follow-through.

Organizations may monitor the proportion of handovers with acknowledgment by designated receiving personnel, the proportion of significant outstanding tasks with identified responsibility and the frequency of tasks remaining unresolved beyond their appropriate timeframe.

They may also examine communication problems identified after shift changes and whether improvement actions reduce recurrence.

These measures require careful interpretation.

An increase in reported handover problems may indicate deteriorating reliability. It may also reflect better reporting and greater willingness among staff to raise concerns.

Similarly, fewer recorded outstanding tasks should not automatically be interpreted as better care if employees have become reluctant to document unfinished work.

Measurement should therefore combine selected operational indicators with examination of actual circumstances.

The distinction between transferred and completed activities is especially important.

A record showing that responsibility was assigned does not demonstrate that the intended support was delivered.

Residents' experiences may also provide useful information.

An older person may report repeatedly explaining the same preference to different caregivers. Another may describe waiting for assistance because each shift believed that another team was responsible.

Such experiences can reveal gaps not apparent in administrative records.

The purpose is not to achieve a perfect documentation score. It is to establish whether important information and responsibilities move reliably between personnel.

These measures should be adapted to the facility's functions and should not be presented as universal safety thresholds, licensing criteria or evidence of regulatory compliance.

Building a Culture of Clear Communication and Accountability

Handover reliability also depends on whether personnel feel able to ask questions and report uncertainty.

A caregiver may hesitate to acknowledge that an activity remains unfinished because they fear criticism.

An incoming employee may avoid asking for clarification because the outgoing team appears rushed.

A less experienced worker may notice an inconsistency but assume that someone with more seniority has already addressed it.

These situations can allow preventable communication gaps to continue.

Facilities should encourage accurate reporting, respectful clarification and appropriate escalation.

Staff should be able to explain that a task remains unfinished without automatically being treated as having failed.

At the same time, openness should not eliminate individual accountability for responsibilities that personnel have agreed and are expected to perform.

A balanced approach recognizes both individual responsibilities and the organizational conditions affecting performance.

Supervisors should support handover arrangements that are practical, consistent and appropriate to staff competencies.

Management should also ensure that staffing and working arrangements allow reasonable opportunities to exchange important information.

Where recurring handover problems are identified, the organization should be willing to review the underlying workflow rather than repeatedly reminding staff to be more careful.

A culture of effective communication does not require lengthy meetings or excessive documentation.

It requires personnel to understand that raising unresolved concerns, acknowledging uncertainty and confirming responsibility are normal parts of dependable care.

Applying the Approach in Viet Nam

Residential long-term care organizations in Viet Nam vary in size, staffing arrangements and service capabilities.

Some facilities operate with small teams and relatively straightforward communication arrangements. Others have several residential areas and personnel with different care and professional responsibilities.

A reliable handover approach should reflect these differences.

A small facility may begin by reviewing its existing communication book and identifying which information requires direct confirmation when shifts change.

A larger organization may need a more structured process across teams, departments and levels of responsibility.

Where licensed healthcare services operate within the organization, clinical handover procedures should be coordinated with routine care handovers while maintaining professional boundaries.

Facilities should also consider how language, terminology and staff preparation affect communication.

A handover system is useful only when the people expected to use it understand the information and know what action is required.

Complex clinical abbreviations or imported templates may create confusion when introduced without appropriate adaptation and training.

International communication methods such as SBAR or I-PASS can offer useful principles, but a hospital-focused approach should not automatically be transferred unchanged into nonclinical residential care.

The preferred method is one that is clear, consistent and suitable for the services actually delivered.

Organizations within the scope of Decree No. 395/2026/ND-CP should consider how their handover arrangements connect with applicable responsibilities for assistance, care planning, case management and records.

However, the proposed HLVN tools should remain clearly distinguished from statutory documentation and reporting obligations.

A useful starting point is often a practical review of one recurring shift change.

Management can observe what information is communicated, identify unfinished activities, determine who receives responsibility and examine whether those activities are addressed during the next shift.

This can reveal important improvement opportunities without requiring a complex information system.

Over time, facilities can refine their approach through staff feedback, residents' experiences and review of operational results.

The objective is not to create the most elaborate handover process. It is to establish a process that personnel can use reliably and that enables residents to receive consistent support as staff change.

Conclusion: A Handover Is Complete When Responsibility Is Clear

Residential long-term care depends on people working together across different hours, roles and responsibilities.

Although staff members change, older residents continue to need assistance, communication and attention to their individual preferences.

A reliable handover helps ensure that these needs remain visible.

Its purpose is not simply to describe what occurred during the previous shift. It is to communicate what the incoming team needs to know, identify unfinished activities and establish who will take the appropriate next action.

Written records support that process, but documentation alone does not guarantee continuity.

Likewise, a verbal handover may communicate information without establishing whether receiving personnel understand their responsibilities.

The proposed Shift Handover Reliability Pathway offers a practical approach built around current information, critical changes, outstanding tasks, acknowledgment of responsibility, follow-through and review.

Its associated tools—the Shift Handover Minimum Information Set, Outstanding Care Tasks and Follow-Up Register, and Shift Handover Reliability Review—can help organizations improve communication without unnecessary administrative complexity.

These resources do not replace statutory requirements or professional clinical handover procedures.

For residential long-term care organizations in Viet Nam, their value lies in making everyday support more reliable and preventing unresolved matters from disappearing when a working shift ends.

A safe handover is not measured only by what the outgoing team communicates. It is measured by whether the incoming team understands what matters, knows what remains unfinished and has clear, workable responsibility for what happens next.

Professional and Regulatory References

Viet Nam

Law on the Elderly No. 39/2009/QH12, as amended, including Consolidated Document No. 23/VBHN-VPQH dated February 26, 2026.

Government Decree No. 395/2026/ND-CP, dated October 23, 2026, on the operation and management of social assistance facilities, scheduled to take effect December 7, 2026, where applicable to the relevant organization.

Law on Medical Examination and Treatment No. 15/2023/QH15, as amended, including Consolidated Document No. 26/VBHN-VPQH dated February 26, 2026, together with applicable implementing regulations where regulated healthcare activities are provided.

Law on Personal Data Protection No. 91/2025/QH15, effective January 1, 2026.

Government Decree No. 356/2025/ND-CP, detailing provisions and implementation measures of the Law on Personal Data Protection, effective January 1, 2026.

Other applicable requirements concerning the operation of social assistance and residential care facilities, professional practice, care documentation, employment arrangements and residents' rights must be determined according to each organization's legal status and actual services.

International

Australian Government. Aged Care Act 2024 and Aged Care Rules 2025, including the strengthened aged care quality framework applicable from November 1, 2025.

Aged Care Quality and Safety Commission, Australia. Strengthened Aged Care Quality Standards, Standard 3: The Care and Services, particularly Outcome 3.3: Communicating for Safety and Quality.

National Institute for Health and Care Excellence (NICE). Managing Medicines in Care Homes, Social Care Guideline SC1 (2014), particularly Recommendation 1.3.7 concerning medicines information during shift handovers.

Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS 3.0: Communication Module — Handoff (2023).

Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards, Second Edition, particularly the Communicating for Safety Standard and guidance concerning structured clinical handover.

World Health Organization. Patient Safety Solution: Communication During Patient Handovers (2007).

World Health Organization. Global Patient Safety Action Plan 2021–2030 (2021).

World Health Organization Regional Office for Europe. Promoting Quality Management in Long-Term Care: Principles, Key Components and Directions for Policy Action (2024).

About This Article

This article is published by Healthy Longevity Vietnam (HLVN) as an independent educational and quality improvement resource addressing the reliability of internal shift-to-shift handover in residential long-term care for older people in Viet Nam.

The discussion focuses on communicating critical information, identifying and following up outstanding care tasks, confirming responsibility, escalating unresolved concerns and improving organizational reliability.

It does not provide a comprehensive clinical handover protocol, prescribe medical or nursing interventions, establish clinical criteria for deterioration or replace professional assessment and decision-making.

The proposed Shift Handover Reliability Pathway, Shift Handover Minimum Information Set, Outstanding Care Tasks and Follow-Up Register, and Shift Handover Reliability Review are organizational quality improvement resources. They are not statutory handover forms, legally prescribed reporting systems, official regulatory assessment methods, accreditation requirements or certification schemes.

International references are provided for professional learning and comparison. Their requirements, particularly those established under Australia's aged care framework or healthcare-specific standards, should not be interpreted as automatically applicable to residential long-term care facilities in Viet Nam.

This article does not constitute legal, clinical or regulatory advice, establish universal handover durations or staffing requirements, or determine responsibility or liability in any particular case.

Organizations should determine the requirements applicable to their legal status, services, personnel, recordkeeping and personal data processing. Matters involving regulated healthcare activities, professional clinical handover, serious safety concerns or legal compliance require appropriate professional assessment.

The purpose of this article is to support reliable communication, clear accountability and continuous improvement while respecting the safety, preferences, privacy and dignity of older residents.

Legal and professional context reviewed: October 27, 2026. Decree No. 395/2026/ND-CP is scheduled to take effect on December 7, 2026.