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: SpO2 below the ordered target or a drop of ≥ 4% with dyspnea; respiratory rate above 28 or below 10; new or worsening dyspnea; a change in sputum color or amount or new hemoptysis; fever with focal findings; or a mental-status change suggesting hypoxia or hypercapnia.
Closed-loop example
“Provider notified at 10:15 of SpO2 88% on the usual 2 L with increased dyspnea and new yellow sputum. Order received to increase oxygen to 3 L within ordered parameters, obtain a chest x-ray and sputum culture, and begin the ordered antibiotic. Patient's SpO2 rose to 93% on 3 L; reassessment arranged in 24 hours and patient instructed to call for further desaturation or worsening dyspnea.”
