The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix C7: Fax Back Orders Sample
Note: This form has been filled out with information for the sample case study patient, Mrs. P.
Date: ____4_____ / _____4____ / ____04____
Return by Fax to: ____Susan_Brown_LPN___________________ Fax #: ____(423)_403-3312_____
Resident Name: __________Mrs._P______________________ Unit/Room: ____401-A__________
Please mark the orders that are appropriate for this resident with an (X) and sign at the bottom.
( ) Psychiatric evaluation to evaluate psychotropic medications
Signature: ______T._Roberts,_MD__________________________ Date: ____4/4/04_______
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