Notify per the resident-specific parameters and policy, and document the closed loop. In the SNF the representative must also be notified on a change of condition (F580).
State the specific parameter/finding that triggered notification.
Record the date/time, who was notified (provider and representative), what was reported (SBAR), the orders received, and the follow-through.
If a response is pending, document the scheduled follow-up time so the loop is not left open.
Closed-loop example
Provider notified at 14:10 of a 4-lb gain over 48 h and new 3+ pretibial edema with a new S3. Order received to increase furosemide per the protocol dose and obtain a BMP within 48 h. Dose administered (witnessed) 14:25; responsible party notified 14:30. Resident reported relief after voiding; reassessment scheduled next shift and the resident/CNA instructed to report further gain or dyspnea.
