Clone of MrXperion

1
Medrad Spectris Solaris
2
BMET Name* This field is required.
First Name
Last Name
3
Email* This field is required.
your.name@trimedx.com
4
Date* This field is required.
Date
Month
Day
Year
5
Work Order Number* This field is required.WOT
6
SID/CEID* This field is required.
7
Hospital Name* This field is required.
8
Department* This field is required.
9
Room* This field is required.
10
Display Serial Number* This field is required.
11
Head Serial Number* This field is required.
12
CRU Version* This field is required.
13
1. Clean/Inspect Display and Main Unit* This field is required.
Pass
Fail
Display Screen
Row 0, Column 0
Row 0, Column 1
Hand Switch
Row 1, Column 0
Row 1, Column 1
Front and Rear Head Covers and Gaskets
Row 2, Column 0
Row 2, Column 1
Display Screen
Hand Switch
Front and Rear Head Covers and Gaskets
Pass
Row 0, Column 0
Fail
Row 0, Column 1
Pass
Row 1, Column 0
Fail
Row 1, Column 1
Pass
Row 2, Column 0
Fail
Row 2, Column 1
1 of 3
14
2. Clean/Inspect Injector Head and Stand* This field is required.
Pass
Fail
Head Covers, Manual Knobs and Gaskets
Row 0, Column 0
Row 0, Column 1
Pedestal Covers and Casters
Row 1, Column 0
Row 1, Column 1
Drive Shaft Cables
Row 2, Column 0
Row 2, Column 1
Syringe Wells and Gasket
Row 3, Column 0
Row 3, Column 1
Integrity of Syringe Wells and Gasket
Row 4, Column 0
Row 4, Column 1
Grease Ball Screws
Row 5, Column 0
Row 5, Column 1
Lens Caps
Row 6, Column 0
Row 6, Column 1
Head Covers, Manual Knobs and Gaskets
Pedestal Covers and Casters
Drive Shaft Cables
Syringe Wells and Gasket
Integrity of Syringe Wells and Gasket
Grease Ball Screws
Lens Caps
Pass
Row 0, Column 0
Fail
Row 0, Column 1
Pass
Row 1, Column 0
Fail
Row 1, Column 1
Pass
Row 2, Column 0
Fail
Row 2, Column 1
Pass
Row 3, Column 0
Fail
Row 3, Column 1
Pass
Row 4, Column 0
Fail
Row 4, Column 1
Pass
Row 5, Column 0
Fail
Row 5, Column 1
Pass
Row 6, Column 0
Fail
Row 6, Column 1
1 of 7
15
3. Operational Checks* This field is required.General Injector Operation Check Phase 1 Contrast A: 5.0 mls, 50 ml Phase 2; Saline B: 10.0 mls, 100 ml 300 psi
Pass
Fail
Date and Time
Row 0, Column 0
Row 0, Column 1
Set Calibration Date
Row 1, Column 0
Row 1, Column 1
General Injector Operation
Row 2, Column 0
Row 2, Column 1
Forward/Reverse Load Buttons
Row 3, Column 0
Row 3, Column 1
Date and Time
Set Calibration Date
General Injector Operation
Forward/Reverse Load Buttons
Pass
Row 0, Column 0
Fail
Row 0, Column 1
Pass
Row 1, Column 0
Fail
Row 1, Column 1
Pass
Row 2, Column 0
Fail
Row 2, Column 1
Pass
Row 3, Column 0
Fail
Row 3, Column 1
1 of 4
16
5. Volume and Flow Rate Checks* This field is required.Injection Duration Syringe A/B: 5.0 ml/s secs, +/- 1 sec. Injection Volume Syringe A/B: 50 ml, +/- 1 ml. Injection Pressure: 300 psi
Seconds
ml
Syringe A 10 secs, +/- 1 sec/50 ml, +/- 1 m
Row 0, Column 0
Row 0, Column 1
Syringe B 10 secs, +/- 1 sec/50 ml, +/- 1 m
Row 1, Column 0
Row 1, Column 1
Syringe A 10 secs, +/- 1 sec/50 ml, +/- 1 m
Syringe B 10 secs, +/- 1 sec/50 ml, +/- 1 m
Seconds
Row 0, Column 0
ml
Row 0, Column 1
Seconds
Row 1, Column 0
ml
Row 1, Column 1
1 of 2
17
PSI Pressure Limit Verification* This field is required.Contrast Side A Pressure Limit: 250 PSI (+/- 50) Flow Rate: 7.5 ml/sec Volume Rate: 60 ml Pressure Limit: 300 psi Saline Side B Pressure Limit: 250 PSI (+/- 50) Flow Rate: 8.0 ml/sec Volume Rate: 800 ml Pressure Limit: 300 psi
PSI Readings
Contrast Side A Pressure Limit: 300 PSI (+/- 50
Row 0, Column 0
Contrast Side B Pressure Limit: 300 PSI (+/- 50
Row 1, Column 0
Contrast Side A Pressure Limit: 300 PSI (+/- 50
Contrast Side B Pressure Limit: 300 PSI (+/- 50
PSI Readings
Row 0, Column 0
PSI Readings
Row 1, Column 0
1 of 2
18
Electrical Safety Test* This field is required.Outputs should read mOhms <150 Output should read mA <500
Out Put Readings
mOhms
Row 0, Column 0
mA
Row 1, Column 0
mOhms
mA
Out Put Readings
Row 0, Column 0
Out Put Readings
Row 1, Column 0
1 of 2
19
Signature* This field is required.
Should be Empty: