Oxygen Therapy Initiation/Titration Note

Date/Time of Note: [Date and time]

Time of O₂ Change: [Time of O₂ change] (Only include if different from note time; if uncertain, state approximate time.)

Author/Role: [Name, credentials] ([RT / RN / MD / APP])

Location: [Unit/bed/setting]

Note Type: [Initiation / Titration / Weaning / Discontinuation]

Order Context: [Provider order / Protocol-driven] (If protocol-driven, include protocol name and criteria met.)

Indication & Target

[Clinical indication and trigger for oxygen therapy or adjustment] (In 2–4 sentences, state why oxygen is being initiated or changed, the specific trigger prompting action, and hypercapnia risk status [COPD / obesity hypoventilation / neuromuscular disease / none identified]. Conclude with the explicit target SpO₂ range with lower and upper bounds. If using a non-standard range, briefly include the rationale. If the indication or target is unclear, state this and note plan to clarify.)

Baseline Assessment

• SpO₂: [SpO₂ %] at [probe site]
• Current Oxygen Setting: [Room air / Device type] at [flow L/min or FiO₂ %]
• Respiratory Status: RR [rate], [work of breathing descriptor]
• Pertinent Exam: [Breath sounds, accessory muscle use, mental status as relevant] (Only include components actually assessed.)
• ABG/VBG: [Type] at [time] on [O₂ setting] — pH [value], PaCO₂ [value], PaO₂ [value], HCO₃⁻ [value] (Only include if obtained.)

Oxygen Order & Titration

Prescription:

• Target SpO₂ Range: [Lower % – Upper %] (Do not infer; document as ordered or protocol default. If not ordered, state the gap and who was notified.)
• Delivery Device: [Nasal cannula / Simple mask / Venturi mask / NRB / Other]
• Setting: [Flow L/min or FiO₂ %]
• Monitoring: [Continuous pulse oximetry / Intermittent checks every __ min]
• Humidification: [None / Bubble / Heated] (Include if used.)

Titration Timeline: (Omit if no changes were made; instead state "No changes made.")

• [Time]: SpO₂ [%] on [device/setting], [symptom descriptor]
• Action: [Device/setting change]
• Reassessment ([interval]): SpO₂ [%], [clinical response, tolerance]
• Decision: [Maintain / Further titrate / Escalate]

(Repeat the above block for each titration step. If reassessment was not possible, document why and who assumed monitoring.)

Plan

• Current Strategy: [Continue current settings / Wean trial / Escalate] (If weaning, specify criteria and step-down approach. If escalating or at risk, list specific triggers for device change, ABG, or rapid response.)
• Notifications: [Who notified, when, response] (Omit if none required.)
• Home Oxygen: [Qualifying SpO₂/PaO₂], [prescribed flows by activity level], [DME coordination status] (Only include if applicable to discharge.)
• Education: [Topics covered] (If deferred, state reason and plan.)

Signature: [Electronic signature], [Credentials], [Timestamp]

(If protocol-driven, include attestation that actions were within protocol parameters.)