Infusion Pump Maintenance Checklist
Use this form to document routine inspection, maintenance actions, test results, findings, and follow-up for an infusion pump.
Equipment Identification
Equipment Asset/Tag ID
*
Pump Model
*
Serial Number
*
Department / Unit / Location
*
Please Select
Emergency Department
Intensive Care Unit
Operating Room
Medical-Surgical Unit
Outpatient Clinic
Other
Maintenance Date
*
 -
Month
 -
Day
Year
Date
Maintenance Type
*
Routine Preventive Maintenance
Scheduled Inspection
Corrective Maintenance
Post-Repair Verification
Inspection and Functional Check
Power-on / self-test result
*
Pass
Fail
Not tested
Display and buttons condition
*
Normal
Damaged
Unresponsive
Other
Alarm / alert functionality
*
Pass
Fail
Not tested
Battery status / charge check
*
Pass
Fail
Not applicable
Occlusion / flow-related check
*
Pass
Fail
Not tested
Tubing / connector condition
*
Normal
Damaged
Leaking
Not applicable
Cleanliness and exterior condition
*
Clean
Needs cleaning
Damaged
Maintenance Actions and Findings
Maintenance Tasks Performed
*
Cleaned
Calibrated
Replaced Parts
Software Check
Battery Replacement
Functional Test
Other
Issues Found
Parts Replaced
Test Values / Calibration Results
Overall Status After Maintenance
*
Operational
Operational with Notes
Out of Service
Follow-up and Completion
Recommended Follow-up Actions
Next Maintenance Due Date
 -
Month
 -
Day
Year
Date
Service Completed By
*
Supervisor/Reviewer Sign-off Name
Completion Notes
Submit Checklist
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