Information
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Sanderling Dialysis Consolidated Daily Audits
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Sanderling Renal Services
102 Crestview Street
Holdenville, OK 74848 -
Conducted on
Water Quality Assurance Checklist
Water Treatment System Quality Assurance Checklist
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The RO must run for 15 minutes before checking pressure gauges. Enter the time the RO was started.
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Enter the time the RO gauges were checked.
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Water alarm audible?
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Water temperature (72-82 degrees)
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Post city booster pump
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City inlet - (PG1)
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Post Multimedia Filter - (PG2)
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Pressure change (PG1 - PG2)
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Post carbon tank #1 (PG 3)
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Pressure change (PG2 - PG3)
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Post carbon tank #2 (PG4)
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Pressure change (PG3 - PG4)
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Post softener (PG5)
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Pressure change (PG4 - PG5)
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Brine tank level?
- 100%
- 90%
- 80%
- 70%
- 60%
- 50%
- <50%
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Why is brine tank below 50%?
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Initial here if the timers are correct?
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Pre-filter pressure (PG6)
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Post filter pressure (PG7) (>20)
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Pressure change (PG6 - PG7)
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Permeate flow rate (Front panel of RO) (> 5gpm)
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Concentrate flow rate (Front panel of RO) ( >2gpm)
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Final pump pressure (Front panel of RO) ( >100psi)
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Feed TDS (Digital panel)
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Permeate TDS (Digital panel)
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% Rejection (Digital panel) ( >90%)
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Permeate conductivity (Digital panel) (<25)
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Pre-UF pressure (PG9)
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Post UF pressure (PG10)
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Loop return pressure (PG11) ( >20 psi)
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Return flow meter ( >5gpm)
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AM Hardness
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Time of am hardness
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Signature of Auditor
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PM Hardness
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Time of pm hardness
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Signature of Person of checked PM hardness
Total Chlorine Test Log
Total Chlorine Test Log
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Total chlorine test
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Date/Time of chlorine test #1
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Result from holding tank.
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Result from carbon tank #1
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Are results less than (<) 0.10ppm
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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.
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Are results less than (<) 0.10ppm
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Dialysis may continue but contact nurse manager, bio-med, and medical director. Total chlorine from Post Carbon Tank #2 MUST BE CHECK HOURLY!!!!
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BREAKTHROUGH TEST LOG! All dialysis must stop! Document the names of everyone contacted including Bio-med. Document resolutions!
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Initials and signature of person performing test.
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Initials and signature of RN reviewing results.
Phoenix Meter Log
Phoenix Meter Log
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Date/Time
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Meter #1
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PH (7.0 +/- 0.1)
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Conductivity (14.0 +/- 0.1)
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Calibrated?
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Disinfected?
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Rinsed?
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Initials
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Meter #2
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PH (7.0 +/- 0.1)
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Conductivity (14.0 +/- 0.1)
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Calibrated?
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Disinfected?
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Rinsed?
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Initials
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Bicarb Meter
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PH (7.0 +/- 0.1)
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Conductivity (100 +/- 2.0)
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Calibrated?
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Disinfected?
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Rinsed?
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Initials
Bicarbonate Mix Log
Bicarbonate Mix Log
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Add batch of bicarbonate
Batch of bicarbonate
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Select date
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How many liters?
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How many bags?
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Enter the lot#
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Product#
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Enter the product#
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Conductivity ( 49 - 53 )
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Sign posted on tank with date, time, and conductivity results.
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Signature of preparer
Glucometer Log
Glucometer Log
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Date/Time
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The following information is found on the bottom of the test strips box.
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Normal range (mg/dl)
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LO range (mg/dl)
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HI range (mg/dl)
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LOT#
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Expiration date:
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Are you using a new bottle of control solution?
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High control result.
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Low control result
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Are they within range?
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Retest
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Normal control result
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Is it within range?
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Retest
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PASS or FAIL
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Signature
AED/Emergency cart daily checklist
AED/Emergency cart checklist
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Date
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Facility
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Cart: Clean, no dirt or contamination; no signs of damage to any packages, etc.
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Two sets of defibrillation pads - sealed, undamaged, not expired
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Spare battery within "Install Before" date and near the AED.
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Data cards (at least one spare), undamaged and present for those AEDs with this feature.
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AED status indicator light shows operational. Passes self test when initiated.
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Emergency cart locked
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Finger-break lock intact on medication tool kit and within expiration date.
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All supplies within expiration date.
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O2 tank intact with full volume and high flow meter valve attached. O2 tank volume verified (log on cart or tape on tank)
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Suction equipment present and operational.
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Check if remarks, problems, corrective action(s) taken. Initial and complete progress notes.
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Signing here states this audit is complete and true.
Bicarbonate tank disinfect log
Bicarbonate Mix Tank Disinfection Log
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Manufacturer states the disinfection of the dissolution module with a diluted bleach solution is required daily.
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Date/Time
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Disinfectant used
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Test positive for presence?
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Test negative for presence (inside tank AND from jug fill)?
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Your signature here states the bicarb mixer has been disinfected and residual test are negative.
Bicarbonate jug disinfection
Bicarbonate Jug Disinfection
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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.
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Date/Time
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Bicarbonate jug 1
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 2
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 3
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 4
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 5
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 6
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 7
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 8
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 9
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 10
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 11
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 12
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 13
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 14
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 15
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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Bicarbonate jug 16
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Test show negative for bleach?
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Your signature states this jug disinfected per policy.
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Your signature states this jug rinsed per policy.
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All caps disinfected per policy.
Hd machine disinfect
Hemo-Dialysis machine daily disinfect log
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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
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HD 101 (1t0s-102897)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 102 (2t0s-109696)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 103 (2t0s-109684)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 104 (1t0s-109168)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 105 (1t0s-104104)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 106 (1t0s-108299)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 107 (1t0s-104768)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 108 (1t0s-108327)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 109 (1t0s-101721)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 110 (9t0s-100016)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 111 (1t0s-104289)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 112 (1t0s-105823)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 113 (1t0s-106060)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 114 (2t0s-111459)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 115 (1t0s-105680)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
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HD 116 (0t0s-100178)
- Acid
- Heat
- Bleach
- Needs repair
- Not used today
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Your signature states this machines was disinfected per policy.
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Is the bleach residual test negative?
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Your signature states this machine disinfected per policy.
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RINSE AGAIN!!!
Sensor log
Sensor log
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Sensors are monitored electronically using Primex Wireless.
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Date/Time
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RN Station #1 Medication Refridgerator (36-46 degrees F)
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Corrective Action
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RN Station #2 Medication Refridgerator (36-46 degrees F)
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Corrective Action
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Prep Room (Lab) Refridgerator (36-46 degrees F)
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Corrective Action
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Treatment room humidity.
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Corrective Action
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Treatment room temperature
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Corrective Action
