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Service-Ventilator
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Service Ventilator
Patient Information
First Name:
Last Name:
Middle:
DOB:
Address:
Phone Number:
Treating Physician:
Insurance:
Member ID
Home Health Care? (Yes/No):
If yes, facility name & phone number:
Ventilator Information
Bedside
Wheelchair
Type:
Model:
Bluetooth:
Yes
No
Vent#:
Operational hour:
Blower hours:
Software version:
SD card size:
HCPC code:
MRX date:
Medical records date:
Ventilator Settings
Circuit Type:
Battery Cycle Internal:
External:
Route of Administration (brand & size)::
Nebulizer enabled:
Primary
Secondary
Alarm Settings
Primary
Secondary
Circuit Disconnect
Low Inspiratory Pressure
High Inspiratory Pressure
Apnea
Apnea Rate
Low VT (e/i)
High VT (e/i)
Low Minute Ventilation
High Minute Ventilation
Low Resp. Rate
High Resp. Rate
Detailed Menu Options
Menu access
Detailed View
Alarm Volume
Keypad Lock
Keypad Backlight
LCD Brightness
Screensaver
Clock Time Set
Language
Settings
Primary
Secondary
Mode
AVAPS (On/Off)
MPV (On/Off)
AVAPS Rate /td>
Target VT
Auto Trak/ Flow Trigger
Sensitivity (LPM)
Cycling sensitivity
IPAP
EPAP/PEEP
Breath Rate (RR)
IT
Pressure Support
Rise Time
Ramp Time
Ramp Pressure
O2 Rate
Comments
Respiratory Care Practitioner:
Date
1329 West Walnut Hill Lane, Suite 100, Irving, TX 75038
1 (866) UNI-MED-2 • 972 228 1820 • FAX (972) 572 1112
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