Da Form 5624 R PDF Details

Ensuring the optimal performance of medical equipment is crucial in any healthcare setting, and the DA Form 5624-R plays a pivotal role in maintaining the quality and safety of defibrillators used within military hospitals and facilities. This form, designated for the meticulous documentation of defibrillator inspections, serves as a comprehensive record-keeping tool for the visual and performance tests carried out on these life-saving devices. By detailing manufacturer information, model specifics, and serial numbers, it facilitates precise identification and tracking of each unit. The form methodically guides inspectors through both visual and functional evaluations, encompassing general condition assessments, the integrity of essential components such as attachment plugs, line cords, paddles, cables, and connectors, as well as vital performance metrics including output energy and charge time. Full or provisional certifications are granted based on the adherence of units to manufacturer specifications, ensuring all deployed defibrillators meet or exceed required operational standards. Consequently, the DA 5624-R not only ensures the reliability of defibrillators in critical moments but also underscores the importance of rigorous maintenance and inspection protocols in safeguarding patient health.

QuestionAnswer
Form NameDa Form 5624 R
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names da form 5624

Form Preview Example

DC DEFIBRILLATOR INSPECTION RECORD

For use of this form, see TB 38-750-2; the proponent agency is OTSG.

HOSPITAL/AREA/LOCATION:

MFR:

MDL:

SERIAL:

ECN:

VISUAL INSPECTION

 

DATE ACTION COMPLETED

PASS

DESCRIPTION OF ACTION NEEDED

 

(YYYYMMDD)

1.GENERAL INSTRUMENT CONDITION

2.ATTACHMENT PLUG

3.LINE CORD AND STRAIN RELIEFS

4.PADDLE, CABLES & CONNECTORS

5.CONTROLS, INDICATORS & METERS

PERFORMANCE TESTS

6.OUTPUT ENERGY (Enter Values in Watt-Seconds)

CONTROL

ENERGY

PREVIOUS

CHANGE

 

 

SETTING

DELIVERED

VALUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. CHARGE TIME AT

 

PREVIOUS VALUE:

MAXIMUM ENERGY

 

 

SETTING:

SEC

SEC

8. INTERNAL DISCHARGE FUNCTION

9. ENERGY DELIVERED AFTER 1 MINUTE AT MAXIMUM

SETTING:

W-SEC

10. OUTPUT OF TENTH REPEATED DISCHARGE:

W-SEC

11.SYNCHRONIZED OPERATION

12.OTHER FEATURES (Specify)

CERTIFICATION

FULL CERTIFICATION WITH LABEL ATTACHED

DATE INSPECTED (YYYYMMDD) NEXT INSPECTION DUE (YYYYMMDD)

PROVISIONAL CERTIFICATION WORK ORDER #:

INSPECTED BY: (Print or Type)

GRADE/RANK:

SIGNATURE

DA FORM 5624-R, MAY 2006

PREVIOUS EDITIONS ARE OBSOLETE.

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INSTRUCTIONS FOR COMPLETING DA FORM 5624-R

HOSPITAL/AREA/LOCATION: Self explanatory.

MFR: Name of manufacturer.

MDL: Use the manufacturer's generic model identification rather than a catalog number.

SERIAL #: The serial number of the defibrillator.

ESN: Equipment Control Number or locally assigned index number.

VISUAL INSPECTION (Items 1 thru 5)

PASS: Visually inspect each of the listed areas and indicate whether they pass with no required action. Enter either YES (Y) or NO (N).

DESCRIPTION OF ACTION NEEDED: Briefly indicate what action is required e.g., replace paddle plates, replace line cord.

DATE ACTION COMPLETED: The date a maintenance work order was completed.

PERFORMANCE TESTS

NOTE: PERFORMANCE TEST WILL BE MADE AFTER THE BATTERIES HAVE BEEN SERVICED.

6. OUTPUT ENERGY.

CONTROL SETTINGS: Indicate the output energy settings available through operator control settings. If more settings are available than space provided, use an equal sampling of low, medium, and high settings.

ENERGY DELIVERED: Indicate the actual delivered energy when measured with calibrated TMDE.

PREVIOUS VALUE: Indicate the "ENERGY DELIVERED" values from the previously filed performance test.

CHANGE: Subtract the "ENERGY DELIVERED" from the "PREVIOUS VALUE." The result can be a negative number.

7.CHARGE TIME: The time it takes to charge to the maximum energy setting. PREVIOUS VALUE: Taken from the previously filed performance test.

8.INTERNAL DISCHARGE FUNCTION: Self explanatory.

9.ENERGY DELIVERED AFTER 1 MINUTE: Self explanatory.

10.TENTH REPEATED DISCHARGE: Self explanatory.

11.SYNCHRONIZED OPERATION: Self explanatory.

12.OTHER FEATURES: Test other special features.

CERTIFICATION

FULL/PROVISIONAL CERTIFICATION: Check one of the boxes.

Full Certification: Unit meets all the manufacturer's specifications.

Provisional Certification: Unit may remain in use and can be used safely but repairs are required (a work order is required when this block

is checked).

DATE INSPECTED: The date a maintenance work order was completed.

NEXT INSPECTION DUE: Self explanatory.

INSPECTED BY: Name of the technician performing the test.

SIGNATURE: Signature of the technician performing the test.

DA FORM 5624-R, MAY 2006

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Step number 1 in submitting Da Form 5624 R

2. Once the previous segment is done, you need to include the essential details in CHARGE TIME AT, MAXIMUM ENERGY, PREVIOUS VALUE, SETTING, SEC, SEC, INTERNAL DISCHARGE FUNCTION, ENERGY DELIVERED AFTER MINUTE AT, SETTING, OUTPUT OF TENTH REPEATED DISCHARGE, WSEC, WSEC, SYNCHRONIZED OPERATION, OTHER FEATURES Specify, and FULL CERTIFICATION WITH LABEL so that you can move forward to the 3rd step.

How you can complete Da Form 5624 R step 2

3. This third step should be fairly easy, FULL CERTIFICATION WITH LABEL, PROVISIONAL CERTIFICATION WORK, DATE INSPECTED YYYYMMDD, NEXT INSPECTION DUE YYYYMMDD, INSPECTED BY Print or Type, GRADERANK, SIGNATURE, DA FORM R MAY, PREVIOUS EDITIONS ARE OBSOLETE, Page of, and APD LC vES - these fields has to be completed here.

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