Virtual CPAP Home Safety Assessment and Patient Education

The checklist used during a virtual CPAP setup to confirm home safety, complete patient education, and document the assessment. Use the printable PDF to capture signatures.

This checklist covers every item that must be confirmed during a virtual CPAP home safety assessment and patient education session. The printable version includes fields for patient name, patient ID, date, and trainer and patient signatures.

General home safety

• Patient confirms a safe and clean environment for CPAP use
• Patient has a stable surface, such as a nightstand or table, near the bed for CPAP placement
• No known tripping hazards near the bed, such as loose rugs or extension cords
• Home temperature and humidity are within a comfortable range for CPAP use
• If the patient is prescribed oxygen for in-home use, oxygen safety and No Smoking signs are posted and oxygen safety rules are followed
• Patient has a working smoke detector in the home

Electrical safety

• Accessible power outlet near the CPAP placement area
• CPAP power cord is in good condition, with no fraying or exposed wires
• CPAP is plugged into a grounded outlet that is not controlled by a light switch
• No overloading of outlets and no use of extension cords

CPAP equipment setup location

• Location is well ventilated, avoiding direct sunlight and heating vents
• CPAP device can be placed at or below head level for optimal function
• Distilled water is available for the humidifier

Emergency preparedness

• Patient has emergency contact information readily available
• Patient confirms a backup power source or a plan in case of a power outage

Patient-specific considerations

• Patient has the physical and cognitive abilities to use and maintain CPAP independently
• Caregiver is available and trained on CPAP usage, if assistance is needed

Patient education

• Patient understands the results of their sleep study and why their prescriber ordered CPAP therapy
• The appropriate mask was determined for the patient and mask fit was verified
• Patient was educated on installing the device and on all of its features
• Patient was educated on routine cleaning and maintenance of the device and all related supplies
• Patient was educated on compliance guidelines, including the required face-to-face physician re-evaluation between days 31 and 91 after initiating therapy for continued coverage
• Patient was educated on how to troubleshoot minor issues and what to do if the CPAP machine malfunctions
• Patient was encouraged to download a compliance and therapy tracker app
• Patient understands that Synapse Health sleep coaches will contact them at periodic intervals during their 90-day compliance period
• Patient understands how to contact Synapse Health to order supplies

Virtual assessment confirmation

• Patient has successfully demonstrated setup and use of the CPAP equipment
• Patient has verbalized understanding of safety precautions and maintenance
• Patient has verbalized the compliance requirements for insurance coverage of the device
• No immediate safety concerns or barriers to CPAP use were identified during the virtual assessment and education

Signatures

The printable form captures a trainer signature and a patient signature, each with a date. Complete both before submitting the assessment.

Questions about the assessment