Oxygen is supplied in accordance with the guidelines of the Thoracic Society of Australia & New Zealand

Domiciliary Oxygen Request Instructions

Please note that incomplete forms will be returned.
Requests must be submitted by 1pm one working day prior to patient discharge.

PAGE 1: Summary of indications for domiciliary oxygen

PAGE 2: Complete section 13 & 14 plus: Section 10 for Continuous
Section 11 for Nocturnal
Section 12 for Exertional *
* not routinely provided on discharge from hospital – refer to summary of indications

DOMICILIARY OXYGEN THERAPY – SUMMARY OF INDICATIONS

Detailed information can be found in the following documents (available on request)–
1. Adult Domiciliary Oxygen Therapy. Position statement of the Thoracic Society of Australia and New
Zealand.
2. SWEP Guidelines for the Provision of Oxygen.
3. DVA Procedural Guidelines for Home Medical Oxygen Therapy.

1. CONTINUOUS 1. PaO2 ≤ 55 mmHg. ABG’s must be taken at rest, after 20mins on room air, on
optimal treatment, not during acute exacerbations or while
clinically unstable.
OR 2. PaO2 56 - 59 mmHg With evidence of right heart failure, pulmonary hypertension
or polycythaemia.
Identify the O2 flowrate which maintains PaO2 > 60 mmHg (SpO2 > 90%).
Note: Prescription should be for ≥16 hours/day to achieve medical benefit.
2. EXERTIONAL Not routinely provided on discharge from hospital. Only provided in the following
circumstances:
- Palliative patients (must provide walk test results unless sever hypoxaemia)
- Exceptional circumstances when approved by a respiratory consultant
In all other instances an oxygen assessment needs to be conducted once the
patient is in a stable phase of the condition, at least 4 weeks post discharge from
hospital. Please complete the domiciliary O2 form and fax the form as a request for
an outpatient oxygen clinic appointment.

Must demonstrate evidence of exercise induced oxygen desaturation on an

exertional test to SpO2 ≤ 88% while breathing room air
PLUS a demonstrable improvement in exercise performance on supplemental O2
PLUS the following additional information –
1. Minimum O2 flowrate required to achieve improvement
2. Patient’s mobility status
Note: Oxygen to be used during mobility only to maintain SpO2 ≥ 90%
3. NOCTURNAL Evidence of oxygen desaturation to SpO2 ≤ 88% based on continuous overnight
SpO2 monitoring during sleep. SpO2 ≤ 88% should occur for greater than /3 of the
1

sleep time. Identify the O2 flowrate that maintains SpO2 > 90%.
4. EMERGENCY Indicated in patients with severe asthma who are prone to sudden, life threatening
episodes.
5. PALLIATIVE Indicated in terminally ill patients with evidence of hypoxaemia (SpO2 < 90%) and a
Concentrator Only life expectancy of less than three months. Oxygen use is for relief of symptoms.
RE-ASSESSMENT REQUIREMENTS
Clinical re-assessment is required for continuous and exertional set-ups occurring in the acute hospital
setting. Reassessment must occur at least 4 weeks after initial assessment, when the patient is in a stable
phase of the condition, in order to determine the ongoing oxygen requirements. Requirements as outlined
above must be met for continuation of oxygen therapy at the 4 week review.
CONTRA-INDICATIONS
1. Chronic condition with PaO2 ≥ 60mmHg 2. Current tobacco smokers.
3. Patients who have not received adequate 4. Patients who are not motivated to use oxygen therapy
therapy of other kinds according to prescription.

Austin Health Domiciliary Oxygen Program - Department of Respiratory Medicine

12/2014
Ph: 03 9496 3669 Fax: 03 9496 3723
 U.R Number …………………………………………..

Surname ………………………………………………

Given Name(s) ………………………………………..

Date of Birth ..…………………………………..…….

Domiciliary Oxygen Request
AFFIX PATIENT LABEL HERE
SECTION 1 – PATIENT DETAILS

Surname ……………………………….… First Name ………………..…………... DVA# / UR# ………..………..

DOB ......./……./……. Sex □ M □ F Address ………………………………………………………….............
Suburb …………………………………… Post Code……………………………… Phone …………………….....
Next of Kin
Name ……………………………………. Relationship ………………………….. Phone …………………….....
GP Details
Name …………………………………….. Address ……………………………..… Phone …………………….....
Does patient have Aged Care funding in place? □ No □ Yes
Service Name............................................................................. Funding type.................................................
Case Manager name.................................................................. Ph............................ Mob.............................
Patient Location at Time of Request □ Public Hosp □ Private Hosp □ Nursing Home □ Patient's Home
Hospital Name & Ward ………………………………………………………Contact Phone ……………………....

Domiciliary Oxygen Request

Discharge Date ......./……./…….
Does Patient Already Have Home Oxygen □ No □ Yes. If yes, Company …………………………………….
If yes, what equipment does patient currently have?........................................................................................
What is current prescription for usage?............................................................................................................

SECTION 2 – DELIVERY ADDRESS

□ Patient’s home (as above)

□ Other address (give details) …………………………………………………………………………………………..

SECTION 3 – THERAPY GROUP SECTION 4 – SMOKING HISTORY

□ Continuous □ Nocturnal □ Exertional Status □ Never □ Current □ Ex

□ Palliative □ Emergency Average cigs/day ………..
Yrs smoked ……
If palliative
Has the patient been referred to Palliative Care Services? □ Yes □ No Date ceased .…/…../….
Is life expectancy <3 months? □ Yes □ No

SECTION 5 – DIAGNOSTIC GROUP (list details) SECTION 6 – MEDICAL EVIDENCE OF

□ COPD □ Cardiac …………………………………………….. Right Heart Failure □ Yes □ No

Polycythaemia □ Yes □ No
□ DILD □ Cancer ……………………………………………..
Pulmonary Hypertension □ Yes □ No
□ Asthmas □ Other ……………………………………………..
SECTION 7 – MEDICATIONS

□ Bronchodilators ………………………………………. □ Inhaled steroids ……….……………………………….

□ Theophylline ………………………………………. □ Oral steroids ……….……………………………….
SECTION 8 – Four Week Review Arrangements
Physician review for 4 weeks after commencing therapy has been planned with ………………………………...
at …………………………………………………………………………………..... on ......./……./…….
Please tick Yes if you wish for the Oxygen Clinic to review the patient for oxygen therapy □ Yes □ No
SECTION 9 – REQUESTED BY
M8.44

Title …….. Name ……………………………….……………......... Specialty ………………………….…………..

Organisation …………………………………… Address …………………………………….……………………...
Suburb ………………………………............... Post Code ………..… Phone …….…….. Pager ………………
Signed …………………………………………. Dated ….../..…./……. Provider Number ………………………..
Austin Health Domiciliary Oxygen Program - Department of Respiratory Medicine
12/2014 Page 1 of 2
Ph: 03 9496 3669 Fax: 03 9496 3723
 U.R Number …………………………………………..

Surname ………………………………………………

Given Name(s) ………………………………………..

Date of Birth ..…………………………………..…….

Domiciliary Oxygen Request
AFFIX PATIENT LABEL HERE

NOTE: Have you also done ABGs on oxygen for patients with Type 2 Respiratory Failure?

SECTION - 10 ARTERIAL BLOOD GASES SECTION - 11 NOCTURNAL SpO2 ASSESSMENT

Date ……./……./……. Room Air Supp O2 Date ……./……./…….
O2 Flow Rate (L/Min) Awake baseline SpO2 (%)
PH Minimum asleep SpO2 (%)
PaCO2 (mmHg) % Sleep time SpO2 ≤ 88%
PaO2 (mmHg)
SaO2 (%)
SECTION 12 - EXERTIONAL OXYGEN ASSESSMENT - 6 Minute walk test
Air O2……L/Min
Time (min) SpO2 HR BORG Time (min) SpO2 HR BORG
Rest Rest
1 1
2 2
3 3
4 4
5 5
6 6
1 post 1 post
2 post 2 post
Distance Distance
SECTION 13 - MOBILITY ASSESSMENT
□ Ambulant & Independent □ Non Ambulant
□ Ambulant with mobility Aid:- □ wheelchair
□ walking frame with basket □ scooter
□ stick
□ crutches
SECTION – 14 OXYGEN REQUIREMENTS
Tick options and specify O2 flow rate & usage O2 Flow
Usage
Rate
□ Continuous □ Palliative □ Nocturnal (L/Min)
(hrs/day)

OXYGEN CONCENTRATOR
TYPE CYLINDER
PORTABLE OXYGEN □ 200L ON EXERTION
(for portable oxygen you MUST complete section 12 &13) □ Carry Bag
□ 400L ON EXERTION
□ Exertional
□ Palliative □ 400L ON EXERTION
□ Trolley
□ 600L ON EXERTION

EMERGENCY □ Asthma Kit: 1500 L Cylinder Kit PRN

Austin Health Domiciliary Oxygen Program - Department of Respiratory Medicine

12/2014 Page 2 of 2
Ph: 03 9496 3669 Fax: 03 9496 3723