General Dialysis Water Treatment Audit - duplicate

• Document No.

• General Audit Title

• Conducted on

  Date

• Prepared by

• Hospital/Clinic Name

• Photo of Hospital/Clinic

  Media
• Address
  Address

• Phone No.

• Doctors Name

• Doctors Email

• Head Nurses Name

• Head Nurses Email

• Technician/s

• Technicians email

• Number of Patients

• Number of Dialysis Stations

• Number of ICU Points

WTS SPECIFICATIONS

• Raw water tank/s and booster pump/s

• Add media

  Media

• Sand/Media Filter-Size-Valve Type- Backwash Flowrate

• Sand/Media Filter

  Media

• Water Softener-Brine Tank Setup

• Water Softener & Brine Assembly

  Media

• Carbon Filtration

• Does the Carbon Filter meet the required EBCT

  Select Yes No

  • Yes
  • No

• Carbon Filters

  Media

• Cartridge Filtration

• Cartridge Filter

  Media

• Brand of Reverse Osmosis System/Manufacturer

• Model I.e. How many membranes? Output of System? Year of Installation?

• Does the Reverse Osmosis Meet ISO 26722

  Yes

  No

• Reverse Osmosis System Photo

  Media

• General comments on Reverse Osmosis System

• Bypass

  Yes

  No

• General Comments of Bypass Arrangement

• Bypass Photos

  Media

• Distribution System type

  Direct Feed

  Indirect Feed

  Direct Feed to Patients and Indirect to Reuse

• Loop Material

  Select PVC ABS PEX Tubing Stainless Steel Other

  • PVC
  • ABS
  • PEX Tubing
  • Stainless Steel
  • Other

• Loop Size

  Select 15mm 20mm 25mm 32mm

  • 15mm
  • 20mm
  • 25mm
  • 32mm

• Approximate Loop Length

  Select 100 metres 150 metres 200 metres 250 metres 300 metres > 300 metres

  • 100 metres
  • 150 metres
  • 200 metres
  • 250 metres
  • 300 metres
  • > 300 metres

• Loop & Outlet Points

  Media

• General Comments of Loop & Outlet Points

• General Comments of WTS Equipment

Reverse Osmosis Tank (ROT)

• Brand/Manufacturer

• Size of Tank in Litres

• Photo of ROT

  Media

• General Comments of ROT

PORTABLE RO

• Number - Make - Model - Age

• Photos of Portable WTS Equipment

  Media

• General Comments on Portable WTS Equipment

Reprocessor Equipment

• Number-Make-Model-Age

• Photo of Reprocessing Equipment

  Media

• General Comments of Reprocessing Equipment