PERFORMANCE CHECKLIST

Name of Hospital
Product Description
Manufacturer
Model
Serial No.
Tanggal
:

:
: Bedside Monitor
: Philips
:
:

Functional Checks
Visual Test
Power On Test

ECG Performance

Target
Sign Damage not
shows
The display
shows ECG
signal of leads

- ECG sinus
rhytm
- HR 60 bpm
- HR 80 bpm
- HR 100 bpm
- HR 120 bpm
- HR 140 bpm

Tools Required
By operator

Passed
Failed

Patient
Simulator

Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed

Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed

- Impedance
1500
- RR Rate 40
rpm

Patient
Simulator

NiBP Test

- 280 mmHg

Manometer

Veni Puncture Check

- 60 mmHg

By operator

IBP Performance

- 0 mmHg
- 200 mmHg

Manometer

SpO2 Check

95
90
85
80

100 %
%
%
%

Temperature Accuracy

- 40O C

Diagnostic Tests
System Log

Target
The log print out is
verified with the
hardware & option
No errors

By operator

Respiration
Performance

Result
Passed
Failed

By operator

Patient
Simulator

Result
Hardware & options :
Error Codes :

Extended Self Test

All items message should

be pass, and no error
message on the display

User Interface Test

Passed
Failed
Test Control
Test Display

All items should work

properly

Test Audio
Test Printer

Pass
Failed
Pass
Failed
Pass
Failed
Pass
Failed

Checked and Tested by :

Ferified by :

(..)

(..)

PERFORMANCE CHECKLIST
Name of Hospital
Product Description
Manufacturer
Model
Serial No.

:
: Defibrillator
: Philips / Agilent / Hewlett Packard
:
:

Functional Checks
ECG Check

Shock Advisory Check

Synchronized
Cardioversion Check

Target
The display
shows ECG
signal of leads
I,II,III & paddle
No Shock
Advice
No Shock
Advice
Shock Advice
5J2J
50 J 15 J

SpO2 Check

95 100 %

Diagnostic Tests
System Log

Target
The log print out is
verified with the
hardware & option
No errors

Result
Passed
Failed
Passed
Paddle
Failed
Shock with NSR
Passed
Failed
Shock with
Passed
Asystole
Failed
Shock with VF
Passed
Failed
Shock with 5 J
Passed
Failed
Shock with 50 J
Passed
Failed
Attach to finger
Passed
Failed
Lead I,II,II

Result
Hardware & options :
Error Codes :

Extended Self Test

All items message should

be pass, except IRDA
(if inactive) & Data Card
(if not present)
All items should work
properly

User Interface Test

Passed / Failed

Test Control
Test Display
Test Audio
Test Printer

ECG Test

The 3 status message

should all be good
(1000 x simulator output)
10%
PC 0 15 ohms
I
50 20 ohms
> 1250 ohms

Defibrillator Test ( AC
Power)
Defibrillator Test ( DC
Power)
Defibrillator Disarm
Test

200 J 30 J
200 J 30 J
0 J or Blank

Battery
Capacity Test
Elapsed Time

Target
85 minutes

Low Battery Time

10 minutes

Checked and Tested by :

PT.BERCA NIAGA MEDIKA

(..)

Passed
Failed
Passed
Failed
Passed
Failed
Passed
Failed

/
/
/
/

Passed / Failed
Peak-to-peak
value:
Metal to metal

Passed /
Failed
Metal to
Passed /
holder:
Failed
Remove paddle Passed /
Failed
Passed
Failed
Passed
Failed
Passed
Failed
Result

Passed
Failed
Passed
Failed

Notes

Ferified by :
RS.

(..)