Facility: _______Greystone_Manor____________________
Address: _________1254_Martin Lane________________
City/State: ______Wilkes,_TN_04321_________________
Telephone: ______(423)_403-4881___________________
Fax: ______(423)_403-3312________________________
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.
(X) Medication changes (please specify)
_______________D/C_Ativan_____________________________________________________
_______________↓_Paxil_to_20_mg_QD_______________________________________
______________________________________________________________________________
( ) Psychiatric evaluation to evaluate psychotropic medications
( ) Optometry evaluation
( ) Ophthalmology consult
(X) Blood for BUN and Creatinine
( ) TED hose during the day
(X) Physical or occupational therapy screen/evaluation of gait/balance/transfer/seating
( ) Other orders:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature: ______T._Roberts,_MD__________________________ Date: ____4/4/04_______
(primary care provider)
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