Healthcare Maintenance Report

HEALTHCARE MAINTENANCE REPORT

Facility and Contact Information

Location of Work / Patient Area

Building/Wing:    Room/Area:    Bed/Station (if applicable):

Equipment / System Details

Maintenance Activity

Date Performed: Day Month Year    Start Time    End Time

Parts / Materials Replaced

Part 1 Description:   Part Number:   Qty:   Cost:

Part 2 Description:   Part Number:   Qty:   Cost:

Safety Checks and Compliance

Equipment Returned to Service: Yes No    If No, describe restriction:

Affected Patient Information (if applicable)

Patient Name:   DOB: Day Month Year

Patient Identifier (MRN or ID):

Privacy Statement: All patient information collected in this report is limited to that required for safe maintenance and is handled in accordance with facility privacy policies and applicable law.

Supervisor Review (Facility Use)

Review Date: Day Month Year

Next Scheduled Maintenance: Month Year

Certification and Liability Acknowledgment

I certify that the maintenance activities described in this report were performed in accordance with applicable manufacturer instructions, facility policies, and safety protocols. I further certify that any tests performed were executed with calibrated equipment and that results recorded are true and accurate to the best of my knowledge. Any known risks to patient care arising from this maintenance activity have been plainly indicated in this report.

The facility retains the right to retain records of this report for regulatory and quality assurance purposes. This report does not alter existing contractual warranties except as expressly documented in vendor agreements.

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