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 or rapid functional decline; an unsafe transfer or a new inability to bear weight or transfer; an inability to manage a critical instrumental activity such as medication management; a caregiver gap leaving needs unmet; or a fall with injury (detail in Safety).
Closed-loop example
“Provider notified at 13:15 of a functional decline — the patient now requires a one-person assist for transfers where previously independent, with unsteady gait — and a gap in caregiver availability. Order received to refer to physical therapy for transfer training and a gait assessment and to evaluate added support. The caregiver was trained in a safe transfer technique; reassessment of function arranged.”
