Notify the provider per the patient-specific parameters and agency policy, and document the closed loop — contact, content, response, and follow-through.
State the specific parameter that was met (the value or finding that triggered notification).
Record the date and time of contact, who was notified, exactly what was reported, the response or orders received, and the follow-through.
If a response is pending, document the scheduled follow-up time so the loop is not left open.
Common notification triggers for this system: any identified risk of harm to self or others (which also triggers the immediate safety response in Section 12); a positive depression or anxiety screen warranting treatment; new or worsening psychotic, manic, or severe-agitation symptoms; psychiatric-medication nonadherence or a significant side effect; a substance-use concern; or an acute behavioral change suggesting a medical or delirium cause.
Closed-loop example
“Provider notified at 11:00 of a positive depression screen (PHQ-9 elevated from baseline) with passive thoughts of being better off not here, but no plan or intent on structured assessment; the patient was not left alone during the assessment and agreed to a safety plan and crisis resources. Order received to arrange an urgent mental-health evaluation and adjust treatment; the 988 Suicide and Crisis Lifeline was provided and reviewed, and follow-up was coordinated.”
