STATUS : Passed Service Required Preventable problem Adverse event likely

Anesthesia Ventilator
Procedure No.
Facility : Dept :
WO No. : Date : Inspector :
Mfr : Model : SN :
CTRL No. : Loc : IPM Time :

QUALITATIVE TASKS
Pass Fail
Chassis / Housing
AC Plug
Line Cord
Filters
Strain Reliefs
Cables
Fittings / Connectors
Controls / Switches
Battery / Charger
Self-Test
Indicators / Display
Time / Date Setting
Network / Wireless Interfaces
Labeling
Alarms
Accessories
Tubes / House
Mount
 Audible Signal
Motor / Fan
Electrodes / Transducer
Heater

QUANTITATIVE TASKS
Set / Indicator Measured Average Acceptability Pass Fail
T1 T2 T3
Parameter
Respiration rate (± 5%) 30
Tidal Volume (±10%) 400
Inspiratory peak flow (±10%) 24
Inspiratory peak pressure (±10%)
PEEP Pressure (±10%)
Minute Volume (±10%)
I:E Ratio (±10%) 1:1
Inspiratory hold (±10%)
Oxygen level (±10%) 100

นางสาวศุภนิดา พรหมมา 6402683