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 cardiovascular notification triggers: blood pressure or heart rate outside ordered parameters; new or worsening edema or weight gain meeting threshold; new chest pain or dyspnea; a new irregular rhythm; symptomatic hypotension; or an abnormal lab (for example, potassium or INR) per protocol.
Closed-loop example
“Provider notified at 14:10 of a 5 lb weight gain over 3 days and new 3+ pretibial edema with a new S3. Order received to increase furosemide to the higher protocol dose and obtain a basic metabolic panel within 48 hours. Patient tolerated the dose and reported relief after voiding; reassessment scheduled in 48 hours and patient instructed to call for further weight gain or worsening dyspnea.”
