Information
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Sanderling Dialysis Consolidated Daily Audits
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Sanderling Staff Assist - Wellington Hills
607 woodland St
Eufaula, OK
Water Quality Assurance Checklist
Water Treatment System Quality Assurance Checklist
Portable RO 1
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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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Pressure gauge (carbon filter 1) (22-45psi)
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Pressure gauge (carbon filter 2)
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Pre-filter pressure gauge (In)
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Pre-filter pressure gauge (out)
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Product water (us/cm)
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Feed water (us/cm)
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Rejection rate (>96%)
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Product water flow (>1100)
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Product water temperature
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Sign and date
Portable RO 2
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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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Pressure gauge (carbon filter 1) (22-45psi)
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Pressure gauge (carbon filter 2)
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Pre-filter pressure gauge (In)
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Pre-filter pressure gauge (out)
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Feed water (us/cm)
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Rejection rate (>96%)
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Product water flow (>1100)
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Product water temperature
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Sign and date
Total Chlorine Test Log
Total Chlorine Test Log
Portable RO #1
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Total chlorine test
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Date/Time of chlorine test #1
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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.
Portable RO #2
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Total chlorine test
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Date/Time of chlorine test #1
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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.
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
Bicarbonate Mix Log
Bicarbonate Mix Log
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Used pre-mix bicarbonate
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Add batch of bicarbonate
Batch of bicarbonate
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Date/Time
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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
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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Bicarbonate jug 1
- Rinsed
- Bleached
- Neg Residual
- Not used
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Your signature states this jug was disinfected per policy.
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Bicarbonate jug 2
- Rinsed
- Bleached
- Neg Residual
- Not used
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Your signature states this jug was disinfected per policy.
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Bicarbonate jug 3
- Rinsed
- Bleached
- Neg Residual
- Not used
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Your signature states this jug was disinfected per policy.
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Bicarbonate jug 4
- Rinsed
- Bleached
- Neg Residual
- Not used
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Your signature states this jug was disinfected per policy.
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Bicarbonate jug 5
- Rinsed
- Bleached
- Neg Residual
- Not used
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Your signature states this jug was disinfected per policy.
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Bicarbonate jug 6
- Rinsed
- Bleached
- Neg Residual
- Not used
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Your signature states this jug was disinfected 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. -
HD 1 (2k0s-9578)
- Acid
- Heat
- Bleach
- Neg Residual
- Not used today
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Your signature states this machines was disinfected per policy.
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HD 2 (7k0s-103915)
- Acid
- Heat
- Bleach
- Neg Residual
- Not used today
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Your signature states this machines was disinfected per policy.
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HD 3 (7k0s-103737)
- Acid
- Heat
- Bleach
- Neg Residual
- Not used today
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Your signature states this machines was disinfected per policy.
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HD 4 (7k0s-104195)
- Acid
- Heat
- Bleach
- Neg Residual
- Not used today
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Your signature states this machines was disinfected per policy.
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HD 5 (4k0s-N768)
- Acid
- Heat
- Bleach
- Neg Residual
- Not used today
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Your signature states this machines was disinfected per policy.
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HD 6 (4k0s-N740)
- Acid
- Heat
- Bleach
- Neg Residual
- Not used today
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Your signature states this machines was disinfected per policy.
