Oxygen Supply Systems

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First name-Last name *

Verification *

Check for MD order for 02 therapy

PPE *

Personal Protection Equipment. Did you use universal precautions, wash your hands, glove and wear eye protection for this procedure?

Gather appropriate 02 Cylinder *

Liquid 02

E cylinder

H cylinder

Other:

Add flowmeter to cylinder *

E cylinder, placed on appropriate pin indexed 02 delivery device

H cylinder, placed on appropriate pin indexed 02 delivery device

If using H cylinder, cracked out outlet before placing flowmeter

Other:

Required

Interface *

What type of 02 interface does the patient have?

02 Flow *

What is the 02 flow

Sp02 *

Chart SP02

Skin *

Did you need to notify the nurse of face or mouth sores from airway pressure or tape skin damage?

Retraints *

Did you check patient restraints?

Clean Up *

Did you clean up the mess you made?

Comments *

Chart any significant concerns

Submit

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