OR Table Equipment and Accessory Audit

• Audit Title

• Department

• Location / Storage area

• Conducted on

  Date

• Prepared by

• Personnel

Device name

Reference number

Mattress integrity

• There is no evidence of perishing; namely changes in color, thickness, strength and texture of the impermeable mattress cover?

  Yes

  No

  N/A

• There are no tears on either sides of the mattress and the cover is intact?

  Yes

  No

  N/A

• Are all the seams intact with no splitting or loose parts?

  Yes

  No

  N/A

• Is the foam recoiling to the standard size when compressed?

  Yes

  No

  N/A

• Is the size of the mattress proportionate to the size of the bed frame?

  Yes

  No

  N/A

Function / Safety

• Is the device complete and with no loose or any missing parts?

  Select Yes No With loose parts With missing part/s Safe to use

  • Yes
  • No
  • With loose parts
  • With missing part/s
  • Safe to use

• Is the device free from any damage?

  Select Yes No With minor dents / bumps / nicks With huge damage Safe to use Some Adjustment is not working

  • Yes
  • No
  • With minor dents / bumps / nicks
  • With huge damage
  • Safe to use
  • Some Adjustment is not working

• Attach photo as necessary

  Media

Proper placement and cleanliness

• Is the device properly placed in the right location?

  Select Yes No In awkward position Mattress are pressed against prominent metal

  • Yes
  • No
  • In awkward position
  • Mattress are pressed against prominent metal

• Is the device clean?

  Select Yes No Minimal stains Huge stain

  • Yes
  • No
  • Minimal stains
  • Huge stain

Employee ID ang Signature

• Employee ID

• Sign here

  Sign

Action Plan / Issue Management

• Date and time of issue report

  Date

• Report received by :

• Employee Id

• Email

• Contact number

• Reported to Manager / Supervisor / Charge Nurse

• Reported to Biomed

• For replacement

• For repair

• To order new Parts

• For evaluation

• Temporary replacement / Back up

• With biomed

• To condemn

Resolved issue

• Was the issue resolved?

  Yes

  No

  N/A

• Repaired / Refurbished

• Replaced / New

• Partial repair

• Temporary Back up Replacement

• Attach photo as needed

  Media

Sign to complete once issue resolved

• Complete

• Employee ID

• Sign here

  Sign