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

Appendix C5: Fax Cover Sheet Sample

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

1. Fax Cover Sheet

Facility: _______Greystone_Manor____________________
Address: _________1254_Martin Lane________________
City/State: ______Wilkes,_TN_04321_________________
Telephone: ______(423)_403-4881___________________
Fax: ______(423)_403-3312________________________

Date: ____4_____ / _____4____ / ____04____

Primary Care Provider: _____Dr._Tom_Roberts_______________ Fax #: __(432)_311-4054__

Resident Name: __________Mrs. P___________________ Unit/Room: ___401-A____________

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: _____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 C5: Fax Cover Sheet Sample. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.