The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix C5: Fax Cover Sheet Sample
Note: This form has been filled out with information for the sample case study patient, Mrs. P.
1. Fax Cover Sheet
Date: ____4_____ / _____4____ / ____04____
Primary Care Provider: _____Dr._Tom_Roberts_______________ Fax #: __(432)_311-4054__
Resident Name: __________Mrs. P___________________ Unit/Room: ___401-A____________
This resident was identified in our Falls Management Program as having a high risk of falls, and underwent a Falls Assessment per our protocol. Attached are the following:
Please review the Falls Assessment Report and return the Fax Back Orders form the next business day. 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