Home Oxygen Qualification Evaluation Report

Header Block

• Patient: [Patient full name] • DOB: [Date of birth] • MRN: [Medical record number]
• Encounter Date/Time: [Encounter date and time]
• Location: [clinic / PFT lab / sleep lab / inpatient unit / home]
• Report Date/Time: [Report generation date and time]
• Report Author: [Name], [Credentials], [Department]
• Ordering/Treating Practitioner: [Name and credentials / Unknown—not provided]; NPI: [NPI / not available]; Clinic: [Clinic or service]; Contact/Fax: [Contact details for routing]
• Report Type: [Initial qualification / Re-qualification or change in status / Continued-payment documentation / Equipment change]

Clinical Indication

[Clinical rationale for oxygen evaluation including primary cardiopulmonary diagnosis relevant to hypoxemia, current symptoms and functional limitation prompting evaluation, current respiratory support status, and smoking status if pertinent to safety] (If indication is unknown, state "Reason for test not provided" without inference. Keep to 2-5 sentences.)

Compliance Preconditions

• Test ordered by treating practitioner: [Yes / No / Unknown]; Ordering date: [Date] (Include date only if Yes)
• Testing entity type: [hospital or clinic lab / physician office / IDTF / sleep lab / other]
• DME supplier involved in test performance or payment: [Yes / No / Unknown]

(If any field is Unknown, note: Clarification is needed before final prescribing.)

Measurement Methodology

• Test type(s) performed: [ABG / spot oximetry / continuous exercise oximetry / overnight oximetry] (Select all that apply)
• Pulse oximeter details: [Device and model if available]; Sensor site: [finger / forehead / ear]; Probe type: [reusable / disposable] (Include only if oximetry performed)
• ABG details: Sampling site: [radial / brachial / femoral]; FiO2 or oxygen setting at draw: [FiO2 or L/min and device] (Include only if ABG performed)
• Patient factors affecting accuracy: [poor perfusion / motion artifact / nail polish / skin temperature / dyshemoglobinemia risk / none documented] (Include only those present)
• Data quality statement: [Adequate signal quality throughout / Artifacts present—brief explanation]

Resting (Awake) Assessment

(Include this section only if resting oximetry or ABG was performed. If not performed, state reason such as "Not performed—ordering clinician requested exertional-only protocol" and omit table.)

Condition	Oxygen Setting	Position	SpO2 (%)}}	HR	Notes
Resting baseline	Room air	[sitting / supine / standing]	[SpO2 value]	[HR value]	[Symptoms or observations]
Resting on oxygen	[Device and L/min or FiO2]	[sitting / supine / standing]	[SpO2 value]	[HR value]	[Notes]

(If ABG performed at rest, include PaO2 and SaO2 values with oxygen condition in Notes column. Include oxygen trial row only if performed.)

Exertional Assessment

(Include this section only if exercise oximetry was performed. If portable oxygen is requested but exertional testing was not performed, add routing warning under Prescriber Action Items.)

• Exercise protocol: [6-minute walk / corridor walk / stairs / ADL simulation]
• Assistive devices used: [none / cane / walker / wheelchair assist]
• Oxygen equipment handling: [Patient carried oxygen / Escort carried / Wheeled cart / Not applicable]
• SpO2 capture method: [continuous / intermittent]

Study Component	Oxygen Setting	SpO2 (baseline / lowest / end)	HR (baseline / peak)	Distance or Time	Symptoms or Stop Reason
1) Pre-exercise rest on room air	Room air	[baseline] / — / [end]	[baseline] / —	[Time at rest]	[Symptoms or notes]
2) Exercise on room air (qualifying exertional value)	Room air	[baseline] / [lowest] / [end]	[baseline] / [peak]	[Distance in meters or time]	[Symptoms or stop reason]
3) Exercise on oxygen (improvement demonstration)	[Device and L/min or pulse-dose setting]	[baseline] / [lowest] / [end]	[baseline] / [peak]	[Distance in meters or time]	[Symptoms or stop reason]

Qualifying exertional value: [Specific SpO2 value, condition, date and time]

Improvement with oxygen demonstrated: [Value(s) demonstrating improvement on oxygen]

Recovery data (supplemental, non-qualifying): [Recovery SpO2, HR, and time if captured] (Omit if not captured)

Overnight Assessment

(Include only if nocturnal testing was performed. Do not use HSAT-derived oximetry as qualifying data. Omit entire section if nocturnal testing not performed.)

• Test type: [Facility-based overnight oximetry / Home overnight oximetry / Polysomnography-derived oximetry]
• Total recorded time: [Hours and minutes]
• Baseline or mean SpO2: [Value %]; Nadir SpO2: [Value %]
• Time below threshold: [Minutes with SpO2 ≤88%] (Include only if device outputs this metric)
• Artifact or excluded time: [Duration and reason] (Include only if applicable)
• OSA and PAP context: PAP prescribed: [Yes / No]; PAP used during test: [Yes / No]; [PSG titration context and study date if PSG-derived] (Include only if patient has OSA)
• Nocturnal-only qualification note: Oxygen qualifies for sleep-only use; portable oxygen not supported by sleep-only qualification. (Include only if nocturnal-only qualification applies)

Time of Need Validation

• Test date(s) and time(s): [List all qualifying test timestamps]
• Clinical status context: [Outpatient symptomatic evaluation / Inpatient anticipating discharge]; Planned discharge date: [Date] (Include discharge date only if inpatient)
• Testing performed at time of need: [Yes / No / Unclear]
• Inpatient timing verification: Test performed [number] days before discharge. (Include only for inpatient; must be within 2 days of discharge)

(If timing is unclear, flag for treating practitioner review before order completion.)

Qualification Determination

• Qualification status: [Qualifies / Does not qualify / Indeterminate—needs additional testing]
• Basis of qualification: [Resting / Exercise / Sleep] (Select all that apply)
• Key qualifying value(s): [Specific values with condition, oxygen setting, and date/time]
• Coverage group: [Group I / Group II / Other]
• Group II criteria documented: [Dependent edema or CHF features / Pulmonary hypertension or cor pulmonale evidence / Hematocrit >56% with source] (Include only if Group II; cite documentation source)
• Portable oxygen: [Supported / Not supported / Indeterminate] (Sleep-only qualification does not support portable oxygen)
• High-flow flag: [Qualifying study performed on ≥4 L/min / Qualifying study NOT performed on ≥4 L/min / Not applicable] (Include only if >4 L/min may be required)
• Governing test when both ABG and oximetry exist: [ABG / Oximetry] (Include only if both performed)
• If Indeterminate—missing data: [List specific data needed to complete determination]

Recommended Oxygen Regimen

(Clinical recommendations to support prescriber decision-making; does not replace the Standard Written Order.)

• Suggested settings:
  • Rest: [L/min / Not indicated]
  • Exertion: [L/min]; [continuous / pulse-dose]; [device details if assessed]
  • Sleep: [L/min / Not assessed]
• Device considerations: Stationary: [Concentrator / other]; Ambulatory: [Portable concentrator / cylinders / liquid oxygen] based on flow needs and mobility; Interface: [Nasal cannula / reservoir cannula / mask]; Humidification: [Recommended / Not required]
• Safety and education: [Smoking cessation counseling status]; [Fire risk counseling completed]; [Home safety review status]; [Patient or caregiver training needs]

(If only qualification testing was performed without titration, note that flow recommendations are preliminary and require prescriber confirmation.)

Prescriber Action Items

• [ ] I reviewed the qualifying blood gas or oximetry study dated [date]
• [ ] I incorporated test results into my chart note or attached this report to the chart
• [ ] I determined home oxygen is expected to improve the patient's condition in the home setting
• [ ] I will place and sign the oxygen order (SWO) including all required elements
• [ ] I reviewed Group II add-on criteria documentation (Include only if Group II applies)

Routing warnings: [Portable oxygen requested but exertional testing not performed / Compliance field unknown—clarification needed / Other coverage gap] (Include only if applicable)

Treating Practitioner Signature
Name: [Printed name] • NPI: [NPI]
Signature: [Signature] • Date/Time: [Date and time signed]

Routing Metadata: Sent to [Destination] via [Fax / EHR message / Secure email] on [Date and time] by [Sender]

Attachments

[List source documents with dates: ABG report, oximetry trend or download, PSG excerpt if used, exercise test worksheet] (If attachments stored elsewhere in EHR, reference document name and location. If not available, state "Source documents not available in chart at time of report.")