Appendix B10: Primary Care Provider Fax Report and Orders (Text Description)

The Falls Management Program Manual

1. Fax Cover Sheet (Text Description)

Facility: ________________________________________
Address: _______________________________________
City/State: ______________________________________
Telephone: _____________________________________
Fax: ___________________________________________

Date: __________ / __________ / __________

Primary Care Provider: ___________________________________ Fax #: __________________

Resident Name: ___________________________________ Unit/Room: ____________________

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:

  1. Falls Assessment Report and suggestions for further assessment and/or intervention.
  2. A form for you to Fax Back Orders on which you can indicate those that you select for this resident.

Please review the Falls Assessment Report and return the Fax Back Orders form the next business day. Thank you.

Falls Coordinator: ______________________________________ Phone number: __________________

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.

2. Falls Assessment Report (Text Description)

Facility: _______________________________________
Address: _______________________________________
City/State: _______________________________________
Telephone: _______________________________________
Fax: _______________________________________
Date: __________ / __________ / __________
Resident Name: _______________________________________

Findings: (X) = positive for this residentSuggestions for further assessment and/or interventions
( ) Medications that could increase fall risk:
  • Review medications and consider changes if appropriate.
  • Consider psychiatric evaluation if indicated to evaluate psychotropic meds
  • Consider consultant pharmacist recommendations.
( ) Low vision
  • Consider optometry or ophthalmology evaluation.
( ) Postural hypotension
≥20 mm Hg drop in systolic pressure with position change
  • Review cardiovascular and diuretic medications.
  • Consider blood work for BUN/Creatinine ratio.
  • Consider TED hose.
( ) Unsafe gait, transfers, and/or wheelchair seating problems
  • Consider OT/PT evaluation.

3. Fax Back Orders (Text Description)

Facility: _______________________________________
Address: _______________________________________
City/State: _______________________________________
Telephone: _______________________________________
Fax: _______________________________________

Date: __________ / __________ / __________

Return by Fax to: ______________________________________ Fax #: ______________________

Resident Name: ______________________________________ Unit/Room: ___________________

Please mark the orders that are appropriate for this resident with an (X) and sign at the bottom.
( ) Medication changes (please specify)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

( ) Psychiatric evaluation to evaluate psychotropic medications
( ) Optometry evaluation
( ) Ophthalmology consult
( ) Blood for BUN and Creatinine
( ) TED hose during the day
( ) Physical or occupational therapy screen/evaluation of gait/balance/transfer/seating
( ) Other orders:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Signature: ______________________________________________ Date: _________________  
                          (primary care provider)

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.

Current as of February 2010
Internet Citation: Appendix B10: Primary Care Provider Fax Report and Orders (Text Description): The Falls Management Program Manual. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanapb10pcptxt.html