CPAP Machine Operational Checklist
Patient Name
First Name
Last Name
Date of Visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Nurse's Name
First Name
Last Name
Equipment & Usage Checklist Task
Rows
Completed?
CPAP machine is present and properly connected
CPAP is turned on and functioning at prescribed pressure
Mask and tubing inspected for air leaks
Tubing and humidifier checked for moisture or signs of mold
Mask is secure, well-fitting, and safe for the patient
Confirm CPAP was tolerated well during previous use
CPAP machine usage confirmed from previous night (ask parent/guardian/caretaker if applicable)
Machine usage report reviewed (if available)
Patient or caregiver reports no discomfort or concerns
Filters cleaned or replaced (if scheduled)
CPAP filters cleaned or replaced (if scheduled)
CPAP machine cleaned after use (according to protocol)
Any malfunction or concern documented and reported to the case manager
Notes / Observations
Signature
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Submit
Should be Empty: