IHORM IG Approved 298 Initial Home Oxygen Risk Mitigation

ihorm ig approved 298 initial home oxygen risk mitigation form (ihorm) and home oxygen consent form (hocf) for new patients only . both

IHORM IG approved 298
Initial Home Oxygen Risk Mitigation Form (IHORM) and Home Oxygen
Consent Form (HOCF) for new patients only .
BOTH FORMS MUST BE COMPLETED AND SIGNED BEFORE OXYGEN CAN BE
INSTALLED.
DO NOT SEND FORMS TO SUPPLIER FORMS WILL BE PLACED IN PATIENT NOTES
THERE ARE CONFIRMATION BOXES ON THE HOME OXYGEN ORDER FORMS.
Oxygen can pose a risk of harm to the user and others in the event of
fires, falls and inability to use complex equipment. The initial
identification and onward communication of these risks is the
responsibility of the health care professional ordering the oxygen and
remains so until that prescription ceases or is superseded. The table
below reflects risk factors that are based on evidence of real life
serious and untoward incidents, 90% of which are smoking and
e-cigarette/charger related.
The Initial Home Oxygen Risk Mitigation (IHORM) is to be completed in
conjunction with the Home Oxygen Consent Form (HOCF) prior to oxygen
being ordered from the oxygen supplier via the Home Oxygen Order Form
(HOOF). It is the responsibility of the registered health care
professional who is gaining consent to complete and add the IHORM with
the HOOF and HOCF to the patient’s notes. If all documents are not
confirmed as being completed in full the Home Oxygen Order cannot be
fulfilled.
If the risks identified on the IHORM indicate significant levels of
risk the patient should be discussed directly with the local Home
Oxygen Service or Clinical Oxygen Lead for a full risk assessment
prior to oxygen being ordered as recommended in the British Thoracic
Home Oxygen Guidelines June 2015. Regardless of risk or diagnosis all
adult patients should be referred the Home Oxygen Assessment and
Review Service (HOS-AR) for the team to determine next steps if deemed
relevant.
If any responses below fall within a shaded box, please refer to the
Required Action column and supporting notes.
All actions should be explained to the patient and why they are being
taken in line with service contracts. Ensure that both verbal and
written information has been given to the patient or their
representative
Patient Name
DOB
Address
Oxygen requested?
Yes - Sending HOOF
No - Risk is too high
Recorded at
Please indicate:- Hospital / Clinic / Home / other location
NHS No
Risk Level
Risks
No
Yes
Required Action
HIGH
Does the patient smoke cigarettes / e-cigarettes?
If a High Risk is identified (shaded box), It is highly recommended
that oxygen is not requested without referral to Home Oxygen
Assessment and Review Service (HOS-AR) or Respiratory Specialist or
support services e.g. falls team, stop smoking service,
Have they smoked in the last 6 months?
Quit date.
Does anyone else smoke at the patients premises?
A recent history of drug or alcohol dependency?
Patient reported they have had a fall in the last 3 months?
Have they had previous burns or fires in the home?
Does the person have identified mental capacity issues?
MODERATE
Can the patient leave their property un-aided?
If 3 or more risks are identified (shaded box),
It is highly recommended that oxygen is not requested without referral
to HOS-AR or Respiratory Specialist or support services e.g. stop
smoking service,
Is the patient or any dependents/ in the property vulnerable? E.G.
disabilities/ children
Do they live in a home that is joined to another?
Patient reports they have working smoke alarms at home? (if unknown
please state no)
Do they live in a multiple occupancy premises (Bedsit/flat)
Mitigation actions taken e.g. contacted falls team Referred to Fire
and Rescue
Declaration I confirm that I am the healthcare professional
responsible for the care of this patient. I have discussed the risks
listed on this form with the patient/carer/ guardian (delete as
necessary) and from the responses given Oxygen can/cannot (delete as
necessary) be requested at this time.
Clinicians Signature
Profession
Print Name
HOS team
Yes / No
Contact No.
Date
Lead Consultant is
(Hospital Discharge only)
P atient agreement to sharing information
Form issued by:
Unit/Surgery
 
Address
Contact name
 
Tel no.
 
Email
Postcode
 
Patient
Name
 
Address
 
D.O.B.
 
NHS number
 
Tel/mobile no.
 
Postcode
 
E-mail
 
(only include if the patient agrees to email contact)
My doctor or a member of my care team has explained the arrangements
for supplying Oxygen at my premises, that my personal information will
be managed and shared in line with the Data Protection Act 1998, Human
Rights Act 1998, and common law duty of confidentiality and I
understand these arrangements, such that:
1.
Information about my condition/condition of the patient named
above* will be provided to the Home Oxygen Service (HOS) Supplier
to enable them to deliver the Oxygen treatment as per the Home
Oxygen Order Form (HOOF).
2.
The HOS Supplier will be granted reasonable access to my premises,
so that the Oxygen equipment can be installed, serviced, refilled
and removed (as appropriate).
3.
Information will be exchanged between my hospital care team, my
doctor, the home care team and other teams (e.g. NHS
administration) as necessary related to the provision, usage, and
review, of my Oxygen treatment, and safety.
4.
Information will also be shared with the local Fire Rescue
Services team to allow them to offer safety advice at my premises
and where appropriate install/deliver suitable equipment for
safety.
5.
Information will also be shared with my electricity
supplier/distributer where electrical devices have been installed.
6.
From time to time, I may be contacted to participate in a patient
satisfaction survey/audit.
(delete should you wish not to participate)
7.
I understand that I may withdraw my consent at any time (at which
point my HOS equipment will be removed).
* Delete as applicable
Patient’s signature
 
Date
 
(see note 4 where signed and witnessed on patient’s behalf)
I confirm that I have responsibility for the above-named patient e.g.
parental responsibility, lasting power of attorney.
Signature
 
Name
 
Relationship to patient
 
Date
 
I confirm that I am the healthcare professional responsible for the
care of this patient and I have completed this form on his/her behalf
as s/he is unable to provide/withhold consent. The patient has been
given a copy of this form.
Clinician’s signature
 
Date
 
Name