Policy Manual sample

MDT Home Health Care Agency, Inc. REQUEST FOR PHYSICIAN’S ORDERS TO DEAL WITH PATIENT FALLS Date of Request: ________________________ Regarding: ___________________________________________________________________ Dr.___________________________________ The above patient has been assessed to be a moderate to high risk for falls. Please review the accompanying Falls Risk Assessment form for results of this assessment. Our Agency has developed a formal Fall Prevention Program and would like to ask for approval to provide the following services to further assess this patient’s risk for falls, to recommend and/or implement preventative measures for falls. Physical Therapy Evaluation for balance and gait assessment, range of motion and strengthening exercises, as well as a home exercise program. Occupational Therapy Evaluation for home safety assessment and assessment for possible adaptive equipment needs. Social Work Evaluation for possible resource procurement to explore options for more assistance, respite care referral, sitter services or other needs. Dietitian Evaluation for adequacy of nutrition intake, education about needed changes in diet for improved nutrition intake and assessment for possible Vitamin D deficiency (studies have shown that a Vitamin D deficiency can be linked to decreased muscle strength, especially in women –– benefit of Vitamin D supplement for those with Vitamin D deficiency is shown to take 6 weeks to 6 months before it is evident). Skilled Nursing increase in services for “Fall Precautions” for two weeks after a fall, which will include two times per week visits for two weeks for orthostatic blood pressure checks, repeat Fall Risk Assessment each week or as needed and evaluation of any medications which may have contributed to the fall. If you would like for the recommended services to be referred, please sign below and fax back at ________________________ or call __________________ if you have any questions. ________________________________ _______________________ Physician Date Home Health Agency Nursing Care & Procedures K-125