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 fall, especially with injury; an immediately dangerous environment; a medication error with potential for harm; an inability to summon help; an elopement risk in a cognitively impaired patient; or any suspected abuse or neglect (which also triggers mandated reporting).
Closed-loop example
“Provider notified at 13:00 of a fall without injury attributable to a throw rug and an unsteady gait, with an elevated fall-risk screen. Order received to refer to physical therapy for a gait and balance assessment and to evaluate for durable medical equipment. The rug was removed, grab bars were recommended, and fall-prevention was taught; reassessment of fall risk arranged.”
