No baseline comparison, SBAR content, time, orders, response, or representative notification — the loop is open.
The closed-loop model note in §4: SBAR with data, orders, administration, representative notification with times, monitoring, and the SCSA determination.
“Resident declined. Sent to hospital.”
No transfer packet, communications, or serial data documented.
The transfer model note: SBAR, transfer order, representative notification, the packet (orders/meds/code status/baseline/reason), serial vitals, and the return SCSA.
“Will continue to monitor.”
For an unresolved change, deferring instead of a set follow-up or escalation.
“Reassess at [time]; escalate if [parameter]; representative to be updated on the result.”
