The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix C4: Fax Alert Sample
Note: This form has been filled out with information for the sample case study patient, Mrs. P.
Date: ____4_____ / _____4____ / _____04___
Physician/NP/PA: ___Dr._Tom_Roberts________________ Fax #: ___(423)_311-4054________
Resident Name:_____Mrs._P___________________________ Unit/Room: ___401-A______
Your patient who is in the Falls Management Program fell on __4/1/04_______. It is this resident's __2___ fall in the past 180 days.
Please consider reviewing the attached suggestions for known risk factors of falls and consider making appropriate recommendations.
Please call the Falls Nurse Coordinator if you have any questions about the incident or suggestions for our Falls Management Program. Thank you.
Falls Coordinator: _____Susan_Brown_LPN__________________ Phone number: __(423)_403-4881__
Confidentiality Statement: The documents accompanying this fax transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by state law. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this fax in error, please notify the sender immediately and shred/destroy all documents.
Page originally created February 2010