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__
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