Attachment C.docx

Attachment C – Priority Patient Concern Form (PPC)

Patient Name: _________Last 4 of SSN: DOB:

VISN 12 Hospital: Date:______________ Time:_________

CHECK ALL THAT APPLY:

ENVIRONMENT PROBLEMS

· Significant and/or hazardous condition within the dwelling which poses a safety or health risk to the patient or others

· Fire evacuation routes not accessible

FIRE SAFETY

· Non‐adherence to oxygen safety instructions

· Observed smoking while on oxygen or indications of smoking while on oxygen

· Indication of oxygen use within 10 feet of ignition source

· Burns to nares/face or noticeable indication of fire or fire damage in the home/residence

PATIENT HEALTH CONCERN

· Emergent health condition/issue observed or relayed by patient/caregiver

– Call 911 if necessary

· Physical impairment preventing the patient from utilizing equipment as prescribed

· Patient appears to have difficulty comprehending/retaining equipment or safety instructions

DETAILED DESCRIPTION OF ADVERSE EVENT/CONCERN AND ACTION TAKEN (MANDATORY):

PLEASE NOTE:

· All PPC issues will be addressed with the patient by the contracted home oxygen supplier and the description of the event, and subsequent education/action will be documented.

· All PPC notifications from the contracted home oxygen supplier are relayed to the corresponding Prosthetics coordinator/section at the servicing VA via phone immediately, and fax sent no later than the next business day.

Reporting Individual (Print) Contractor Site:

VA 1617 Priority Patient Concern (VISN 12) Rev 03/27/2025