P.M. CHECKLIST FOR ECG

CUSTOMER:_________________________________
MANUFACTURER:____________________________
MODEL:_____________________________________
SERIAL NUMBER:_____________________________

1. Servo gain: Pass __ Fail __ Adjusted __
2. Stylus damping: Pass __ Fail __ Adjusted __
3. Stylus limits: Pass __ Fail __ Adjusted __
4. Paper speed accuracy: Pass __ Fail __ Adjusted __
5. 1 mv cal. verification with external precision source: Pass __ Fail __ Adjusted __
6. Verification of correct lead selection: Pass __ Fail __ Adjusted __
7. Check type of primary lead selection: Direct __ Manual Indirect __ Auto Indirect __
8. If unit is direct switching, inspect switch contacts: Pass __ Cleaned __ Replaced __
9. Servo linearity test: Pass __ Fail __ Adjusted __
10. Complete & attach 12 lead ECG (if required): Yes __ No __
11. Decay time: Pass __ Fail __

Complete this section only for units utilizing thermal matrix array

1. Printhead pressure: Pass __ Fail __ Adjusted __
2. Printhead skew: Pass __ Fail __ Adjusted __
3. Inspect passive backing: Pass __ Fail __
4. Check type of backing: Kapton __ Synthetic Rubber __
5. Segment activation Pass __ Fail __ Adjusted __
6. Drive supply voltage: Pass __ Fail __ Adjusted  __

If unit is interpretive complete this section

1. Program used: Bonner __ Mortara (MAC) __ New Mortara __ Tokyo Univ. __ Other __
2. Storage battery: Pass __ Fail __ Replaced __
3. Memory digitalization filtering: Pass __ Fail __
4. Complete and attach arrhythmia detection accuracy record: Yes __ No __

Comments and corrective action: _____________________________________________
_________________________________________________________________________
Date tested: ___________________
Tested by: ____________________