Siemens Polydoros SX LX User manual
Erlwein
POLYDOROS SX/LX
Maintenance Protocol
POLYDOROS
Generator
Customer:
Address:
AX
Department:
Room:
Contact person:
Telephone:
Cust. specific no.:
Cust. no.:
Date.:
The instructions RX63-055.831.02.02.02 are required for
this protocol
Print No.:
Replaces: RX63-055.832.02.01.02
RX63-055.832.02.02.02
© Siemens AG
The reproduction, transmission or use
of this document or its contents is not
permitted without express written
authority. Offenders will be liable for
damages. All rights, including rights
created by patent grant or registration
of a utility model or design, are
reserved.
English
Doc. Gen. Date: 04.05
2002
Cust.-No.: Date: Protocol
1Protocol
SIEMENS Office:
Address:
Region:
Country:
Contact person:
Tel.:
CSE in charge:
Tel.:
Remarks Regarding the Protocol:
The protocol is valid as proof of quality for one check that must be performed on the system / component in one year.
The check must be performed in the specified intervals.
The results of the check are entered in this protocol.
The chapter numbers in front of the checkpoints indicate the corresponding chapters in
the particular instructions (see cover page).
The protocol must be completely filled out by the Customer Service Engineer, i.e.:
• All boxes must be filled out. If a box does not apply to the system or if no entry needs to
be made, check the “n.a.“ box.
• Enter the customer number (Cust. No.:) and the date of the check in the header of each
page so that each page can be allocated to a customer and to a check date.
• If there are complaints, the IVKs for the component about which a complaint has been
made as well as the type of complaint must be entered in the “Open Points“ table provided for this. Correction of these open points also must be documented in this table
with the date and a signature. If there are no open points, check “No“ and document this
with the date and a signature.
• If movable components (also test phantoms that are part of the system) that can be
used in different systems are used for the check, they must be entered in the “Movable
Components“ table provided for this.
• The measurement values for the measurements that must be performed during the
check must also be entered in the open spaces / tables provided for them.
• After completing the check, Page 3 of this protocol must be filled out and signed.
POLYDOROS SX/LX RX63-055.832.02.02.02 Siemens AG
04.05 CS PS 211
Page 2 of 10
Medical Solutions
Protocol Date: Cust.-No.:
Further Processing and Archiving of the Protocol
The protocol is a document and thus must be archived. After completing the test, it must
be filed in the corresponding register in the “System Owner Manual“ binder. If needed, a
copy can be handed to the customer.
System:
Serial No.:
Software Version:
Number of the Service Contract:
Type of Maintenance:
Evaluating the Condition of the System / Component
The system has no deficiencies. The image quality test
resulted in no differences from required reference values.
The system / component has slight deficiencies that have
no affect on continued operation of the system. However
they should be corrected preventively.
The image quality test resulted in no differences from
required reference values.
The system / component has serious deficiencies. For
safety reasons, continued operation of the system is permitted only after successfully correcting the deficiencies.
After completing all work steps, an evaluation was performed.
Signature:
Date: Name:
The operator or a person assigned for this has taken note of this evaluation.
(if national regulations require this)
Signature:
Date: Name:
Siemens AG RX63-055.832.02.02.02 POLYDOROS SX/LX
Medical Solutions
04.05 CS PS 211
Page 3 of 10
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