1.ICN:

LiverpoolSt Helens &Knowsley

2.Patient Details:

Age:<40yrs40-54yr 55-64yrs65-74yrs>75yrs

Gender:MaleFemale

Primary Diagnoses: ______

3.Patient Location:

HomeHospital In-patientHospice IPUHospital OPD

Hospice OPD Other (please specify) ______

4.Was the patient:

Already on oxygen Commenced on oxygenDon’t Know

5.Was indication for oxygen clearly documented?

YesNoDon’t Know

6.What was the indication for oxygen?

HypoxiaSymptom controlTo improve mobilityImprove prognosis  Patient request  Family request 

Other (please specify)______Not documented 

7. For patients already on oxygen, was any documentation available as to what Oxygen the patient had been prescribed?

YesNoDon’t KnowNot already on oxygen 

8. Is there evidence that Oxygen has been titrated?

YesNoNo need for titrationInappropriate

9.Were any side-effects noted:

None noted Dry nose/eyes/mouth  Pressure sores to ears/nose Claustrophobia  Drowsiness Social isolation Risk of falls 

Fire risk Loss of independence Reduced prognosisOther……………..

Please answer Questions 12-15 for Hospice or Hospital in-patients ONLY

10. (a) Was oxygen clearly prescribed?

YesNoDon’t Know

(b) Was flow rate specified on the prescription?

YesNoDon’t KnowOxygen not prescribed

(c) Was % specified on the prescription?

YesNoDon’t Know Oxygen not prescribed

(d)Was system of delivery specified on the prescription?EgFace mask, nasal specs

YesNoDon’t Know Oxygen not prescribed

11.Was a target saturation documented?

YesNoDon’t Know

If Yes, what was it?______

12.How often were oxygen saturations recorded?

More than once daily DailyAs per symptoms

NeverNot appropriate to check

13.Discharge:

Was patient discharged on Oxygen?

YesNoDon’t Know

If not, why not?______

14.If home oxygen was ordered, did you encounter any of the following problems? (Tick all that apply)

Home oxygen not ordered Obtaining HOOF form Contacted to amend HOOF form Fax not received  Delivery issue

Difficulty supplying ambulatory oxygen 

15.If home oxygen was ordered, was the GP given the following information:

(a) That the patient had been given home oxygen

YesNoDon’t KnowN/A

(b) They type of oxygen supplied eg LTOT, ambulatory

YesNoDon’t KnowN/A

(c) The flow rate or percentageprescribed

YesNoDon’t KnowN/A

16. Was a patient information leaflet given?

YesNoDon’t Know