Water Quality Assurance Checklist

Water Treatment System Quality Assurance Checklist
The RO must run for 15 minutes before checking pressure gauges. Enter the time the RO was started.
Enter the time the RO gauges were checked.

Water alarm audible?

Water temperature (72-82 degrees)

Post city booster pump

City inlet - (PG1)

Post Multimedia Filter - (PG2)

Pressure change (PG1 - PG2)

Post carbon tank #1 (PG 3)

Pressure change (PG2 - PG3)

Post carbon tank #2 (PG4)

Pressure change (PG3 - PG4)

Post softener (PG5)

Pressure change (PG4 - PG5)

Brine tank level?

Why is brine tank below 50%?

Initial here if the timers are correct?

Pre-filter pressure (PG6)

Post filter pressure (PG7) (>20)

Pressure change (PG6 - PG7)

Permeate flow rate (Front panel of RO) (> 5gpm)

Concentrate flow rate (Front panel of RO) ( >2gpm)

Final pump pressure (Front panel of RO) ( >100psi)

Feed TDS (Digital panel)

Permeate TDS (Digital panel)

% Rejection (Digital panel) ( >90%)

Permeate conductivity (Digital panel) (<25)

Pre-UF pressure (PG9)

Post UF pressure (PG10)

Loop return pressure (PG11) ( >20 psi)

Return flow meter ( >5gpm)

AM Hardness

Time of am hardness
Signature of Auditor

PM Hardness

Time of pm hardness
Signature of Person of checked PM hardness

Total Chlorine Test Log

Total Chlorine Test Log
Total chlorine test
Date/Time of chlorine test #1

Result from holding tank.

Result from carbon tank #1

Are results less than (<) 0.10ppm

Perform a Total Chlorine Test on Post Carbon Tank #2 and enter the results in this box. If Post Carbon Tank #2 results are greater than (>) 0.10ppm, STOP PATIENT TREATMENTS IMMEDIATELY. Notify the charge nurse, nurse manager, and medical director for further instructions. Document post carbon tank #2 results on Breakthrough Test Log.

Are results less than (<) 0.10ppm

Dialysis may continue but contact nurse manager, bio-med, and medical director. Total chlorine from Post Carbon Tank #2 MUST BE CHECK HOURLY!!!!

BREAKTHROUGH TEST LOG! All dialysis must stop! Document the names of everyone contacted including Bio-med. Document resolutions!

Initials and signature of person performing test.
Initials and signature of RN reviewing results.

Phoenix Meter Log

Phoenix Meter Log
Date/Time

Meter #1

PH (7.0 +/- 0.1)

Conductivity (14.0 +/- 0.1)

Calibrated?

Disinfected?

Rinsed?

Initials

Meter #2

PH (7.0 +/- 0.1)

Conductivity (14.0 +/- 0.1)

Calibrated?

Disinfected?

Rinsed?

Initials

Bicarb Meter

PH (7.0 +/- 0.1)

Conductivity (100 +/- 2.0)

Calibrated?

Disinfected?

Rinsed?

Initials

Bicarbonate Mix Log

Bicarbonate Mix Log

Add batch of bicarbonate

Batch of bicarbonate
Select date

How many liters?

How many bags?

Enter the lot#

Product#

Enter the product#

Conductivity ( 49 - 53 )

Sign posted on tank with date, time, and conductivity results.

Signature of preparer

Glucometer Log

Glucometer Log
Date/Time

The following information is found on the bottom of the test strips box.

Normal range (mg/dl)

LO range (mg/dl)

HI range (mg/dl)

LOT#

Expiration date:

Are you using a new bottle of control solution?

High control result.

Low control result

Are they within range?

Retest

Normal control result

Is it within range?

Retest

PASS or FAIL

Signature

AED/Emergency cart daily checklist

AED/Emergency cart checklist
Date

Facility

Cart: Clean, no dirt or contamination; no signs of damage to any packages, etc.

Two sets of defibrillation pads - sealed, undamaged, not expired

Spare battery within "Install Before" date and near the AED.

Data cards (at least one spare), undamaged and present for those AEDs with this feature.

AED status indicator light shows operational. Passes self test when initiated.

Emergency cart locked

Finger-break lock intact on medication tool kit and within expiration date.

All supplies within expiration date.

O2 tank intact with full volume and high flow meter valve attached. O2 tank volume verified (log on cart or tape on tank)

Suction equipment present and operational.

Check if remarks, problems, corrective action(s) taken. Initial and complete progress notes.

Signing here states this audit is complete and true.

Bicarbonate tank disinfect log

Bicarbonate Mix Tank Disinfection Log

Manufacturer states the disinfection of the dissolution module with a diluted bleach solution is required daily.

Date/Time

Disinfectant used

Test positive for presence?

Test negative for presence (inside tank AND from jug fill)?

Your signature here states the bicarb mixer has been disinfected and residual test are negative.

Bicarbonate jug disinfection

Bicarbonate Jug Disinfection

Policy (T500-02) explains Bicarb Jug Disinfection. Jugs that are used during the treatment day will be rinsed daily with RO water and A 1:100 bleach solution will be used once per week. Jugs in storage and not used for more that 48 hours will be disinfected before use.

Date/Time

Bicarbonate jug 1

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 2

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 3

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 4

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 5

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 6

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 7

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 8

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 9

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 10

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 11

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 12

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 13

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 14

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 15

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.

Bicarbonate jug 16

Test show negative for bleach?

Your signature states this jug disinfected per policy.
Your signature states this jug rinsed per policy.
All caps disinfected per policy.

Hd machine disinfect

Hemo-Dialysis machine daily disinfect log

HD machine undergo acid cleaning whenever exposed to bicarb. (Policy 375-01-13)
HD machine undergo chemical disinfection weekly. (Policy 03-104-13)
HD machine undergo heat disinfect daily, except after chemical disinfect.

Date/Time
HD 101 (1t0s-102897)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 102 (2t0s-109696)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 103 (2t0s-109684)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 104 (1t0s-109168)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 105 (1t0s-104104)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 106 (1t0s-108299)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 107 (1t0s-104768)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 108 (1t0s-108327)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 109 (1t0s-101721)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 110 (9t0s-100016)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 111 (1t0s-104289)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 112 (1t0s-105823)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 113 (1t0s-106060)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 114 (2t0s-111459)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 115 (1t0s-105680)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

HD 116 (0t0s-100178)
Your signature states this machines was disinfected per policy.

Is the bleach residual test negative?

Your signature states this machine disinfected per policy.

RINSE AGAIN!!!

Sensor log

Sensor log

Sensors are monitored electronically using Primex Wireless.

Date/Time

RN Station #1 Medication Refridgerator (36-46 degrees F)

Corrective Action

RN Station #2 Medication Refridgerator (36-46 degrees F)

Corrective Action

Prep Room (Lab) Refridgerator (36-46 degrees F)

Corrective Action

Treatment room humidity.

Corrective Action

Treatment room temperature

Corrective Action

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.