Control Number: ____________
Room #____________
Patient Room Check List
==========================================================================
X = Repairs needed OK = No Defects Found
1. First Visual . . . . . . . . . . . . . . . . . . . . . . ____________
2.0 AC OUTLETS
Mechanical Integrity Check . . . . . . . . . . . (EST# 1)____________
3.0 BED
(Shaft)
3.1 Head Elevator Check . . . . . . . . . . . . (Timing)____________
(Shaft)
3.2 Foot Elevator Check . . . . . . . . . . . . (Timing)____________
(Shaft)
3.3 Height Elevator Check . . . . . . . . . . . (Timing)____________
3.4 Cable Check . . . . . . . . . . . . . . . . . . . . ____________
4.0 NURSE CALL
(Bed)
4.1 Call Intialization. . . . . . . . . . . . . . (Bath)____________
4.2 Call Cancel . . . . . . . . . . . . . . . . . . . . ____________
5.0 BPM
5.1 Cuff and Tubing Check . . . . . . . . . . . . . . . ____________
5.2 Calibration . . . . . . . . . . . . . . . . . . . . ____________
6.0 TELEVISION
6.1 Pillow Speaker Check. . . . . . . . . . . . . . . . ____________
6.2 Picture Quality Check . . . . . . . . . . . . . . . ____________
7.0 TELEPHONE
(Cables)
7.1 Visual . . . . . . . . . . . . . . . . . . .(Label)____________
7.2 Function Check . . . . . . . . . . . . . . . . . . ____________
8.0 AIR SUPPLY
8.1 Visual Check . . . . . . . . . . . . . . . . . . . .____________
8.2 Function Check . . . . . . . . . . . . . . . . . . .____________
9.0 ELECTRICAL SAFETY
9.1 Continuity Check. . . . . . . . . . . . . . (EST #3)____________
9.2 Leakage Test. . . . . . . . . . . . . . . . (EST #4)____________
10.0 FINAL VISUAL . . . . . . . . . . . . . . . . . . . . . . ____________
Technician:__________________ Date:__________
Technician:__________________ Date Repairs
