|
For CPAP Setup patients
|
|
|
Plan of Care
|
|
|
Date of SetUp
|
SSN/ID # and D.O.B
|
|
Home Address
|
Phone number
|
|
Referring Physician
|
Diagnosis
|
|
|
|
|
Initial Setup / Prescription
|
|
|
CPAP________________
|
|
|
Initial ramp________________
|
|
|
Initial pressure reading________________
|
Flow rate__________
|
|
Oxigen Titration__________
|
|
|
|
|
|
Functional Limitations__________
|
|
|
Activities permited__________
|
|
|
Teaching assessment__________
|
|
|
Family/caregiver support__________
|
|
|
|
|
|
Type of Service: Pick Up
|
|
|
|
|
|
Equipment / Supplies
|
Manufacturer
|
|
CPAP Machine
|
Make, Model and size
|
|
|
Serial Number_________ device _____.
|
|
Mask
|
Make, Model and size
|
|
Humidifier
|
Make, Model and size
|
|
Headgear
|
Make, Model and size
|
|
Tubing
|
Make, Model and size
|
|
Chin Strap (if needed)
|
Make, Model and size
|
|
Nasal Cushion (if needed)
|
Make, Model and size
|
|
|
|
|
|
|
|
|
|
|
Instruction Checklist for Home Medical Equipment
|
|
|
Others receiving instructions
|
|
|
Physician Orders
|
|
|
Goal
|
|
|
|
|
|
Objectives
|
|
|
Pt demonstrates proper set up / usage of equip?
|
|
|
Pt understand how to clean and maint. of equip?
|
|
|
Pt understands purpose / significance of CPAP ?
|
|
