Water Quality Assurance Checklist

Water Treatment System Quality Assurance Checklist
Portable RO 1
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.

Pressure gauge (carbon filter 1) (22-45psi)

Pressure gauge (carbon filter 2)

Pre-filter pressure gauge (In)

Pre-filter pressure gauge (out)

Product water (us/cm)

Feed water (us/cm)

Rejection rate (>96%)

Product water flow (>1100)

Product water temperature

Sign and date
Portable RO 2
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.

Pressure gauge (carbon filter 1) (22-45psi)

Pressure gauge (carbon filter 2)

Pre-filter pressure gauge (In)

Pre-filter pressure gauge (out)

Feed water (us/cm)

Rejection rate (>96%)

Product water flow (>1100)

Product water temperature

Sign and date

Total Chlorine Test Log

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

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.
Portable RO #2
Total chlorine test
Date/Time of chlorine test #1

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.

Phoenix Meter Log

Phoenix Meter Log
Date/Time

Meter #1

PH (7.0 +/- 0.1)

Conductivity (14.0 +/- 0.1)

Calibrated?

Disinfected?

Rinsed?

Initials

Bicarbonate Mix Log

Bicarbonate Mix Log

Used pre-mix bicarbonate

Add batch of bicarbonate

Batch of bicarbonate
Date/Time

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

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.

Bicarbonate jug 1
Your signature states this jug was disinfected per policy.
Bicarbonate jug 2
Your signature states this jug was disinfected per policy.
Bicarbonate jug 3
Your signature states this jug was disinfected per policy.
Bicarbonate jug 4
Your signature states this jug was disinfected per policy.
Bicarbonate jug 5
Your signature states this jug was disinfected per policy.
Bicarbonate jug 6
Your signature states this jug was disinfected 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.

HD 1 (2k0s-9578)
Your signature states this machines was disinfected per policy.
HD 2 (7k0s-103915)
Your signature states this machines was disinfected per policy.
HD 3 (7k0s-103737)
Your signature states this machines was disinfected per policy.
HD 4 (7k0s-104195)
Your signature states this machines was disinfected per policy.
HD 5 (4k0s-N768)
Your signature states this machines was disinfected per policy.
HD 6 (4k0s-N740)
Your signature states this machines was disinfected per policy.
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.