Oxygen Home Safety Assessment

Client Information

Date of Assessment *

Reason for Assessment

Name of Assessor

Assessors Email *

Client Name

Date of Birth

Allergies/Advert Events

Is the client on blood thinners?

YesNoUnsure

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Are there any alerts in place?

YesNoN/A

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Are there any communication devices/interpreters required?

YesNoOther

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Does the client live alone?

YesNo

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General Practitioner Information

Practice Name

Doctors Name

GP Medication Authority attached?

YesNoN/AOther

GP Medication Authority

Browse

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Is the GP Summary Attached?

YesNoOtherN/A

GP Summary attachment

Browse

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Vital Signs

Heart Rate

RegularIrregular

Blood Pressure Sitting

Blood Pressure Standing

Respiratory Rate

Temperature

Oxygen Saturation

Is the client displaying shortness of breath?

YesNoOtherN/A

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Describe the clients skin colour

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Oxygen

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Is the client on 24/7 oxygen?

YesNo

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Is the client using oxygen PRN?

YesNo

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How is the oxygen managed when the client is sleeping?

Client managedFamily managedOther

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Where does the client sleep?

BedReclinerOther

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How much oxygen does the client use in a 24 hour period?

1 litre2 litres3 litresOther

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Is the client on a portable oxygen cylinder?

YesNoOther

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Is the client on a Home Oxygen Concentrator?

YesNoOther

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Where is the Home Oxygen Concentrator located in the home?

If the client is leaving the house, is a portable oxygen cylinder in use?

YesNoOther

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How is the oxygen used?

Nasal canulaFacemaskHumidifierOther

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Who is the provider taking care of the oxygen cylinder maintenance/delivery of the cylinder?

Does the client have any spare oxygen cylinders at home?

YesNoOther

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What is the plan if there is a power outage or any issues with electricity?

Notify Care Manager to follow upNotify Care Manager to update the client risk alertOther

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Has the Care Manager followed up with the Oxygen Provider if the client has notified the fire department and/or the electricity company that they are using oxygen?

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Are there 'Oxygen in use' signs visible within the residence?

YesNoOtherN/A

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Is the client using any tubing or extension when using their oxygen?

YesNoOtherN/A

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Is the extension/tubing a tripping hazard?

YesNoOtherN/A

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Does the client use oxygen near an open flame?

YesNoOtherN/A

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Is anyone assisting the client with their cooking?

YesNoOtherN/A

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Has any education been provided to the client about placing their tank/cylinder near an open flame?

YesNoOtherN/A

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Does the client visit a Respiratory Specialist?

YesNoOther

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Is the client a smoker?

YesNoVapingOther

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Is anyone in the home smoking?

YesNoN/A

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Recommendations

Final Draft of the Assessment

Yes

Care Managers Email:Care Managers email address is their first name @sensiblecare.com.au (eg. mary@sensiblecare.com.au)

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