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: an acute change in mental status, new confusion, or a fluctuating level of consciousness (a delirium concern); a new focal neurologic sign with a cognitive change; cognitive impairment creating an imminent safety danger; behavioral symptoms posing a risk; or a capacity concern affecting safety or consent.
Closed-loop example
“Provider notified at 10:15 of an acute change in mental status — new confusion and inattention with a fluctuating course and a positive CAM — concerning for delirium in a patient with a recent decline in intake. Order received to evaluate for an infectious or metabolic cause and obtain laboratory studies, with instruction to activate emergency response for a decline in consciousness. The caregiver was educated on delirium and safety; urgent evaluation was coordinated.”
