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: pain persistently above the patient's goal despite the regimen; new pain or a change in pattern, location, or quality; signs of opioid-related respiratory depression or excess sedation; uncontrolled adverse effects (constipation, nausea); or pain with red-flag features (new neurologic deficit or signs of an acute process).
Closed-loop example
“Provider notified at 13:20 that the patient's pain remained 7/10 above the goal of 3/10 despite the scheduled regimen, limiting ambulation, with no adverse effects. Order received to increase the around-the-clock dose and add a bowel regimen. Pain reassessed at 4/10 after the adjusted dose with improved ambulation; bowel and safety teaching reinforced; reassessment arranged.”
