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: a new pressure injury or non-blanchable erythema (routed to Wounds / Pressure Injury); a suspected deep-tissue injury; signs of skin infection (spreading erythema, warmth, or fever); a serious skin reaction; or significant new skin breakdown.
Closed-loop example
“Provider notified at 11:20 of new non-blanchable erythema over the sacrum (a Stage 1 pressure injury) in a patient with a Braden score indicating high risk. Order received to initiate a pressure-redistribution surface and a two-hourly repositioning schedule and to refer for wound care. Offloading and prevention were instituted and taught; reassessment of the area arranged.”
