Gas Exchange Assessment Form
Use this form to record gas exchange observations, assessment context, and follow-up notes. Keep the same title exactly as written everywhere in the form.
Assessment Overview
Patient/Subject ID
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessment Type/Location
*
Baseline
Follow-up
Pre-intervention
Post-intervention
Other
Reason for Assessment
Gas Exchange Findings
Respiratory Rate (breaths/min)
*
Oxygen Support Status
*
Room air
Nasal cannula
Simple face mask
Non-rebreather mask
High-flow oxygen
Mechanical ventilation
Other
Observed Breathing Effort
*
1
2
3
4
5
Gas Exchange Indicators
*
Rows
Absent
Mild
Moderate
Severe
Shortness of breath
1
2
3
4
Cyanosis
5
6
7
8
Use of accessory muscles
9
10
11
12
Overall work of breathing
13
14
15
16
Interpretation and Follow-up
Overall gas exchange impression
*
Normal
Mild impairment
Moderate impairment
Severe impairment
Critical impairment
Indeterminate
Clinician notes / recommended next steps
Follow-up urgency / reassessment timing
*
Please Select
Immediate escalation
Repeat assessment within 1 hour
Repeat assessment within 4–6 hours
Reassess within 24 hours
Routine follow-up
No immediate follow-up needed
Submit Gas Exchange Assessment Form
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