REASSESSMENT FOR CONTINUED MEDICAL ELIGIBILITY – RESTING HYPOXEMIA AND EXERTIONAL ONLY
Reassessment must be done one to three months post initial eligibility/ treatment initiation
Check appropriate box(es) (To be verified/completed by regional designate)
Referral will NOT be processsed unless completed in full and results attached: ABG/Walk Test
Resting Hypoxemia: Client meets at least one of the following parameters AND supplemental oxygen is required at least
18 hours per day.
Adults
• ABG on Room Air - no closer than one (1) month and not greater than three (3) months from date of Initial HOCP Entry ABG:
PaO
2
<
−
59 mmHg
Pediatric (Children 17 years of age and under)
• Yearly testing that meet the British Thoracic Society Guidelines for oxygen therapy in children
Exertional Oxygen
ABG on room air – One (1) result of PaO
2
>59 mmHg AND
One of:
Evidence of desaturation on room air during exertion to SpO
2
<89% for a minimum of one (1) minute (Blinded six (6) minute walk
test administered with documented improved performance on oxygen versus room air (include distance walked increases by 25%
and a minimum of 30 metres)
During the course of the Blinded six (6) minute walk test, evidence of desaturation on Room Air during exertion, to SpO
2
<80% for
a minimum of one (1) minute (i.e., test may be terminated; no need to demonstrate objective measured improvement)
Regional Home Oxygen _______________________________________________ Date ________________________________
Administrator or designate Print name / signature (dd/mm/yyyy)
Disposition of Referral – Continued Medical Eligibility for HOCP
NOTE: Palliative Oxygen and Nocturnal Oxygen are exempt from reassessment for continued medical eligibility
Approved Not Approved
Reason _________________________________________________________________________________
Approved Regional Respiratory Authorizer, ______________________________________________ Date _____________________________
or Designated Provincial Respiratory Print name / signature (dd/mm/yyyy)
Consultant
(January 2018)
TO BE RETAINED ON THE CLIENT COMMUNITY RECORD
Disposition of Referral – Initial Medical Eligibility for HOCP
Approved
Not Approved Reason _____________________________________________________________________________
Approved Regional Respiratory Authorizer, ____________________________________________ Date ________________________
Regional Home Oxygen Administrator, Print name / signature (dd/mm/yyyy)
Palliative Care Program Professional or
Designated Provincial Respiratory Consultant
2 of 2
Client name: PHIN:
Oxygen Prescription / Delivery Mode
Continuous__________litres/min Exertion __________litres/min Nocturnal __________litres/min
Via:
Nasal
Other (describe):
________________________________________________________________________
Prongs
Referring physician, physician assistant or ____________________________________________ Date ________________________
nurse practitioner Print name / signature (dd/mm/yyyy)
Date of follow-up testing:
