The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

Appendix C4: Fax Alert Sample

Note: This form has been filled out with information for the sample case study patient, Mrs. P.

Facility: __Greystone_Manor_&_Rehab_________
Address: __1254_Martin_Lane_________________
City/State: __Wilkes,_TN_04321_________________
Telephone: __(423)_403-4881___________________
Fax: __(423)_403-3312___________________

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__

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 last reviewed December 2017
Page originally created February 2010
Internet Citation: Appendix C4: Fax Alert Sample. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.