Intellivue Monitor PM Checklist
Email
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Service Order No.
Date
*
/
Day
/
Month
Year
Date
Customer Information
Entity
Location
Equipment Information
Monitor Model
Serial No
Software Revision
FMS/FMX
Serial No
Software Revision
Measurement Server
Serial No
Software Revision
MMS Extension
Serial No
Software Revision
CHECKLIST
1. Visual test
Pass
Fail
Pass Selected
O
Fail Selected
O
2. Power ON Test
Pass
Fail
Pass Selected
O
Fail Selected
O
3. Alarm Test
Pass
Fail
Pass Selected
O
Fail Selected
O
4. ECG Performance Test
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
5. Respiration Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
6. ECG Out Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
7. SpO2 Performance Test
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
8. NBP Performance Test
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
9. Invasive Pressure Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
10. Temperature Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
11. Mainstream CO2 Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
12. Sidestream CO2 Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
Sidestream CO2 Performance Test [Opt] Serial No
Fill in Serial No. if Pass
13. Microstream CO2 Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
14. Recorder Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
Recorder Performance Test [Opt] Serial No.
Fill Serial No. if Pass
15. Cardiac Output Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
Cardiac Output Performance Test [Opt] Serial No
Fill Serial No. if Pass
16. BIS Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
BIS Performance Test [Opt] Serial No
Fill in Serial No. if Pass
17. NMT Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
NMT Performance Test [Opt] Serial No
Fill in Serial No. if Pass
18. FloTrac Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
FloTrac Basic Performance/FloTrac Performance [Opt] Serial No
Fill in Serial No. if Pass
19. IntelliBridge Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
IntelliBridge Performance [Opt] Serial No
Fill in Serial No. if Pass
20. Masimo O3 Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
Masimo O3 Performance Test [Opt] Serial No
Fill in Serial No. if Pass
21. Masimo SedLine Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
Masimo SedLine Performance Test [Opt] Serial No
Fill in Serial No. if Pass
22. EEG/SO2 Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
EEG/SO2 Performance Test [Opt] Serial No:
Fill in Serial No. if Pass
23. Battery Status Check [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
24. Nurse Call Relay Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
25. MSL Assurance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
26. Intellivue 802.11 Bedside Adaptor Communication Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
27. LAN Communication Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
28. IIT Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
29. SRR Performance Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
30. Mount Integrity Test [Opt]
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
31. Other Regular Test (Touchscreen calibration/Disabling Enabling Touch Operation/ Printer Test Report)
Pass
Fail
NA
Pass Selected
O
Fail Selected
O
NA Selected
O
32. Safety Tests (S1, S2, S3, S4)
Pass
Fail
Pass Selected
O
Fail Selected
O
Tabulated Test Results
4. ECG Performance Test
NA
HR = 120 ± 2 BPM
NA Selected
5. Respiration Performance Test
NA
RR = 45 ± 2 RPM
NA Selected
7. SpO2 Performance Test
NA
Between 95% to 100%
NA Selected
8a. NBP Accuracy Test
NA
NBP = 280 ± 3 mmHg
NA Selected
8b. NBP Leakage Test
NA
Leakage test value ≤ 6 mmHg
NA Selected
8c. NBP Linearity Test
NA
NBP = 150 ± 3 mmHg
NA Selected
8d. NBP Valve Test
NA
Value displayed on Monitor ≤ 10 mmHg within 5 seconds
NA Selected
9. Invasive Pressure Performance Test (P1)
NA
P1 = 200 ± 5 mmHg
NA Selected
9. Invasive Pressure Performance Test (P2)
NA
P2 = 200 ± 5 mmHg
NA Selected
9. Invasive Pressure Performance Test (P3)
NA
P3 = 200 ± 5 mmHg
NA Selected
9. Invasive Pressure Performance Test (P4)
NA
P4 = 200 ± 5 mmHg
NA Selected
10. Temperature Accuracy 1
NA
Temp 1 = 40 ± 0.2 ℃
NA Selected
10. Temperature Accuracy 2
NA
Temp 2 = 40 ± 0.2 ℃
NA Selected
10. Temperature Accuracy 3
NA
Temp 3 = 40 ± 0.2 ℃
NA Selected
11. Mainstream CO2 Accuracy Test
NA
36 mmHg ~ 40 mmHg (5% of Ambient Pressure @ 760 mmHg)
NA Selected
12a. Sidestream CO2 Accuracy Test
NA
36 mmHg ~ 40 mmHg (5% of Ambient Pressure @ 760 mmHg)
NA Selected
12b. Sidestream CO2 Flow Check
NA
40 ml/min ~ 60 ml/min (5% of Ambient Pressure @ 760 mmHg)
NA Selected
13a. Microstream CO2 Leakage Check, Part 1 [M3015A, HW A & B]
NA
Value of part 1 on Flowmeter = < 4.0 ml/min
NA Selected
13a. Microstream CO2 Leakage Check, Part 2 [M3015A, HW A & B]
NA
Value of part 2 on Flowmeter = < 4.0 ml/min
NA Selected
13a. Microstream CO2 Leakage Check [M3015A, HW C or M3015B]
NA
Value of barameter < 20 mbar for 30 seconds
NA Selected
13b. Barametric Pressure Check
NA
Difference between display and measured value < 12 mmHg
NA Selected
13c. Sidestream CO2 Pump Check [M3015A HW A only]
NA
Difference displayed on M800XA = > 120 mmHg
NA Selected
13d. Microstream CO2 Flow Check
NA
Difference between measured value = 50.0 + 15 / -7.5 ml/min
NA Selected
13e. Microstream CO2 Noise Check
NA
Noise Index displayed on M800XA =<3.0
NA Selected
13f. CO2 Gas Calibration Check
NA
Difference between measured CO2 value, based on 5% CO2 cal. gas = ± 2.6 mmHg
NA Selected
13g. CO2 Calibration Verification
NA
Difference between measured CO2 value, based on 10% CO2 cal. gas = ± {0.07 x value calculated}
NA Selected
15. Cardiac Output Test
NA
C.O = 5 ± 1 l/min
NA Selected
16. BIS Performance Test, PIC/DSC Test
NA
Electrode 1 (+): 4~6 kΩ
NA Selected
16. BIS Performance Test, PIC/DSC Test
NA
Electrode 2 (ref): 8~17 kΩ
NA Selected
16. BIS Performance Test, PIC/DSC Test
NA
Electrode 3 (1-): 2~4 kΩ
NA Selected
16. BIS Performance Test, PIC/DSC Test
NA
Electrode 4 (2-): 3~5 kΩ
NA Selected
Engineer’s Details
Engineer's Name
*
Engineer's Signature
*
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