Messaged NP via portal 14:30. SBAR: S — patient with weight gain +3 lb/24 hr, new bibasilar crackles, and 2+ ankle edema; denies chest pain or significant rest dyspnea. B — CHF on furosemide 40 mg daily; last echo EF 35%. A — concern for early decompensation; BP 138/82, HR 92, SpO₂ 94% RA, no acute distress. R — request consideration of a diuretic increase or a BMP/BNP order; will recheck weight and call back if not improved by tomorrow. Response pending; will follow up by 16:00 today and update the POC if an order is received.
When the response is pending, document a specific follow-up time, not “will follow up.” When orders come back, document the order received, the action taken, and the patient’s response. The full loop is: contact → content → order → action → outcome.
Closed-loop with order received
NP returned the call 15:10 with an order: furosemide 80 mg PO today, then resume 40 mg daily; BMP in 48 hours. Order verified, dose administered (witnessed) 15:25. Reinforced fluid restriction and the weight log. Will recheck weight, vital signs, and lung sounds next visit and reassess the need to escalate.
What auditors see in a clean coordination note
A timestamp, a name, a method, a clear ask backed by data, and either an order received or a defined next step. Every coordination event in the chart should pass this checklist.
