Biomed eService Report Biomedical Engineering

St. Lukes Medical Center Clinical Engineering Department

Quezon City Page 1 of 6
Anesthesia Machine
(Pre-use Checklist)
Unit: OPTHA-OR Room#: 1 Date: November 28 2019
Brand / Model / Serial #: GE/CARESTATION 650

QUALITATIVE TEST
No. Pass Fail Description No. Pass Fail Description
1.1 ✔ Chassis / Housing 1.11 ✔ Filters
1.2 Mount / Fasteners 1.12 ✔ Controls / Switches
1.3 ✔ Casters / Brakes 1.13 ✔ Indicators / Displays
1.4 ✔ AC Plug / Receptacles 1.14 ✔ Self Test
1.5 ✔ Line Cord 1.15 ✔ Time/Date Settings
1.6 ✔ Strain Reliefs 1.16 ✔ Labeling
1.7 Circuit Breakers / Fuses 1.17 ✔ Flowmeters
1.8 ✔ Tubes / Hoses 1.18 Gas Cylinder
1.9 ✔ Cables 1.19 Humidifier
1.10 Fittings / Connectors 1.20 Accessories

PRE-OPERATIONAL TEST
No. Pass Fail Description No. Pass Fail Description
2.1 ✔ Alarm System 2.6 ✔ Funtion Test/ Leak Test
APL Valve Test & Pressure Relief
2.2 ✔ Audible Signals 2.7 ✔ Test
Inspiratory & Expiratory Non-
2.3 ✔ Back-up Battery Test 2.8 ✔ return Valve Test

2.4 ✔ Ventilator Internal Test 2.9 ✔ Bag / Ventilator Switch Test

Leak Test Absorber Canister
2.5 ✔ Oxygen Flush Valve 2.10
Detached

PREVENTIVE MAINTENANCE
No. Pass Fail Description No. Pass Fail Description
3.1 Calibration of Spirometery 3.3 ✔ Condensate Drainage

3.2 Calibration of Oxygen Monitor 3.4 Cleaned Unit

Comments/Remarks:
Ongoing

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St. Lukes Medical Center Clinical Engineering Department
Quezon City Page 2 of 6
Operative Cluster
(Equipment Checklist)

Unit: OPTHA-OR Room# : 1

STANDARD MACHINES AND EQUIPMENT FOUND INSIDE THE OR THEATER

Power on Self test
NO. Description Brand / Model / Serial# Remarks
Passed Failed
1 Anesthesia Machine GE/CARESTATION 650 ✔ W/ scav no bag hose
2 Capnometer ( AGM ) DE483B8534
3 Cautery Machine
Penlon/d0710-0823 ✔
4 Gas Vaporizers
✔
✔ Berchtold 11682
5 OR Lights
Berchtold ✔
6 OR Table DEXTA / E062300-7 ✔ Eye Force 3478

7 Patient Monitor (Cables) CRITICARE POET PLUS/108237855 ✔ DE483B8534

SPECIAL EQUIPMENT FOUND INSIDE THE OR THEATER AS ENDORSED/RESERVED BY THE SURGEON
Power on Self test
NO. Description Brand/Model/Serial# Remarks
Passed Failed
1
2

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Anesthesia Machine
(Pre-use Checklist)
Unit: OPTHA-OR Room#: 2
Brand / Model / Serial #: OHMEDA/AESTIVA/AMVJ0312

QUALITATIVE TEST
No. Pass Fail Description No. Pass Fail Description
1.1 ✔ Chassis / Housing 1.11 ✔ Filters
1.2 Mount / Fasteners 1.12
✔ Controls / Switches
1.3 ✔ Casters / Brakes 1.13 ✔ Indicators / Displays
1.4 ✔ AC Plug / Receptacles 1.14 ✔ Self Test
1.5 ✔ Line Cord 1.15 Time/Date Settings
1.6 ✔ Strain Reliefs 1.16 ✔ Labeling
1.7 Circuit Breakers / Fuses 1.17 ✔ Flowmeters
1.8 ✔ Tubes / Hoses 1.18 ✔ Gas Cylinder
1.9 ✔ Cables 1.19 Humidifier
1.10 Fittings / Connectors 1.20 Accessories

PRE-OPERATIONAL TEST
No. Pass Fail Description No. Pass Fail Description
2.1 ✔ Alarm System 2.6 ✔ Funtion Test/ Leak Test
APL Valve Test & Pressure Relief
2.2 ✔ Audible Signals 2.7 ✔ Test
Inspiratory & Expiratory Non-
2.3 ✔ Back-up Battery Test 2.8 ✔ return Valve Test
2.4 ✔ Ventilator Internal Test 2.9 ✔ Bag / Ventilator Switch Test
Leak Test Absorber Canister
2.5 ✔ Oxygen Flush Valve 2.10
Detached

PREVENTIVE MAINTENANCE
No. Pass Fail Description No. Pass Fail Description
3.1 Calibration of Spirometery 3.3 ✔ Condensate Drainage

3.2 Calibration of Oxygen Monitor 3.4 Cleaned Unit

Comments/Remarks:
Performed pre-use procedure in accordance to manufacturer's recommendation. Unit passed and ready to use.

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Operative Cluster
(Equipment Checklist)

Unit: OPTHA-OR Room# : 2

STANDARD MACHINES AND EQUIPMENT FOUND INSIDE THE OR THEATER

NO. Description
1 Anesthesia Machine
2 Capnometer ( AGM )
3 Cautery Machine
4 Gas Vaporizers
Power on Self test
Brand / Model / Serial# Remarks
Passed Failed
OHMEDA/AESTIVA/AMVJ0312 ✔ Amvh00284 W/ scav
CRITICARE POET IQ/308034712 ✔ Philips ashe0004
Penlon/DO3090187 ✔ BEJS05740

BERCHTOLD / D530 / 11684 ✔

5 OR Lights
BERCHTOLD / D650 / 11935 ✔
6 OR Table DEXTA / E062300-7 ✔ Eyeforce 4890
7 Patient Monitor (Cables) CRITICARE POET PLUS/308241094 ✔
SPECIAL EQUIPMENT FOUND INSIDE THE OR THEATER AS ENDORSED/RESERVED BY THE SURGEON
Power on Self test
NO. Description Brand/Model/Serial# Remarks
Passed Failed
1
2

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Anesthesia Machine
(Pre-use Checklist)
Unit: OPTHA-OR Room#: 3
Brand / Model / Serial #: Ohmeda/Aestiva/AMVJ00312
QUALITATIVE TEST
No. Pass Fail Description No. Pass Fail Description
1.1 ✔ Chassis / Housing 1.11 ✔ Filters
1.2 Mount / Fasteners 1.12 ✔ Controls / Switches
1.3 ✔ Casters / Brakes 1.13 ✔ Indicators / Displays
1.4 ✔ AC Plug / Receptacles 1.14 ✔ Self Test
1.5 ✔ Line Cord 1.15 Time/Date Settings
1.6 ✔ Strain Reliefs 1.16 ✔ Labeling
1.7 Circuit Breakers / Fuses 1.17 ✔ Flowmeters
1.8 ✔ Tubes / Hoses 1.18 ✔ Gas Cylinder
1.9 ✔ Cables 1.19 Humidifier
1.10 Fittings / Connectors 1.20 Accessories

PRE-OPERATIONAL TEST
No. Pass Fail Description No. Pass Fail Description
2.1 ✔ Alarm System 2.6 ✔ Funtion Test/ Leak Test
APL Valve Test & Pressure Relief
2.2 ✔ Audible Signals 2.7 ✔ Test
Inspiratory & Expiratory Non-
2.3 ✔ Back-up Battery Test 2.8 ✔ return Valve Test
2.4 ✔ Ventilator Internal Test 2.9 ✔ Bag / Ventilator Switch Test
Leak Test Absorber Canister
2.5 ✔ Oxygen Flush Valve 2.10
Detached

PREVENTIVE MAINTENANCE
No. Pass Fail Description No. Pass Fail Description
3.1 Calibration of Spirometery 3.3 ✔ Condensate Drainage

3.2 Calibration of Oxygen Monitor 3.4 Cleaned Unit

Comments/Remarks:
Performed pre-use procedure in accordance to manufacturer's recommendation. Unit passed
and ready to use.no wagd hose

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Operative Cluster
(Equipment Checklist)

Unit: OPTHA-OR Room# : 3

STANDARD MACHINES AND EQUIPMENT FOUND INSIDE THE OR THEATER

Power on Self test
NO. Description Brand / Model / Serial# Remarks
Passed Failed
1 Anesthesia Machine Ohmeda/Aestiva/AMVJ00312 ✔
2 Capnometer ( AGM ) CRITICARE POET IQ/308034718 ✔ Philips/ashe-0004
3 Cautery Machine
Penlon/d0710-0823 ✔
4 Gas Vaporizers

berchtold/6010040-j 11685 ✔
5 OR Lights
berchtold/5910040-J 11938 ✔
6 OR Table DEXTA / E062300-7 ✔ Brumba
7 Patient Monitor (Cables) CRITICARE POET PLUS/308241094 ✔ Philips/DE483B8442
SPECIAL EQUIPMENT FOUND INSIDE THE OR THEATER AS ENDORSED/RESERVED BY THE SURGEON
Power on Self test
NO. Description Brand/Model/Serial# Remarks
Passed Failed
1
2

Time Performed by: Acknowledged by:

Start: 9 30 PM
Completed: 9 50 PM E. Basilio/ Lalaine F. Edu

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