PATIENT MONITOR PREVENTIVE MAINTENANCE

Hospital Name Unit Type

Division Serial Number
Contact Person Date Checked

ELECTRICAL SAFETY TEST

No. Tested Items Pass Fail N/A Range Remarks
1 Enclosure Leakage Current £ 100 mA
2 Earth Leakage Current £ 300 mA
3 Patient Leakage Current £ 10 mA
4 Patient Auxiliary Current £ 10 mA

EQUIPMENT CHECK ACCESSORIES CHECK

Checked Items OK Not OK N/A Checked Items OK Not OK N/A
Casing Battery
Warning Label ECG Cables
Buttons & Trim Knob SpO2 Cables
Connector & Cables Temp Cables
Display / Touch Screen NIBP Tubing & Cuff
Recorder Power Cord

PARAMETER TEST / CALIBRATION

No. Tested Parameters Test Setting Test Result Result Tolerance Remarks

80 bpm ± 1 bpm
1 ECG
Calibration
□ Calibrated
5%
□ Not Calibrated
2 RESP 40 rpm ± 2 rpm
96% ±2%
3 SpO2
80 bpm ± 3 bpm
100 80 87
± 5 mmHg
200 166 177
4 NIBP Leakage Test □ Pass □ Fail Pass

Calibration
□ Calibrated
Pass
□ Not Calibrated
200 mmHg ± 2 mmHg
5 IBP
Calibration
□ Calibrated
Completed
□ Not Calibrated
6 Temperature 37 ⁰C ± 0.2 ⁰C

Note : Engineer Signature,

Name :
 DEFIBRILATOR QUALITY CONTROL

Hospital Name Unit Type

Division Serial Number
Contact Person Date Checked

EQUIPMENT CHECK ACCESSORIES CHECK

Checked Items OK Not OK N/A Checked Items OK Not OK N/A
Casing Battery
Warning Label ECG Cables
Buttons & Trim Knob SpO2 Cables
Connector & Cables Power Cord
Display
Recorder

USER TEST

No. Tested Parameters Test Setting Test Result

Mode Select knob PASS

All hardkeys on the equipment’s PASS

1 Control Test front panel
Audio test PASS
Display test PASS

Energy Delivery Energy delivery test delivers a 200J

2 PASS
Test external discharge

Batteries PASS
Mainboard PASS
3 Routine Test
Defib/Pacer function PASS
Monitor function PASS
Note :
Engineer Signature,

Name :

PT MEGAH MEDIKA PHARMA