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

Appendix C7: Fax Back Orders Sample

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

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)




( ) 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)

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 C7: Fax Back Orders Sample. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.