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
Cust.-No.: Date: Protocol
Explanation of Abbreviations in the Protocol
Abbrev. Explanation Abbrev. Explanation
SI Safety Inspection PMF Preventive Maintenance, Operat-
ing Value Check, Function Check
SIE Electrical Safety Inspection Q System Quality, Image Quality
SIM Mechanical Safety Inspec-
QIQ Image Quality
tion
PM Preventive Maintenance QSQ System Quality Check
PMP Periodic Preventive Mainte-
SW Software Maintenance
nance
PMA Preventive Maintenance
CSE Customer Service Engineer
Adjustments
Additional activities performed
Only activities that are not described in the instructions for the system / component need
to be listed.
Date:
Additional activities performed:
OK not OKn.a.
Open Points:
Yes: No: Signature:
Date: Name:
If “Yes“, enter the component with the IVK and the open point (only the number) in the
table. After completing maintenance, record this in the table.
IVK Component Open Points Completed
Date Signature
POLYDOROS SX/LX RX63-055.832.02.02.02 Siemens AG
04.05 CS PS 211
Page 4 of 10
Medical Solutions
Protocol Date: Cust.-No.:
Measuring Devices queried electronically:
Yes: No: Signature:
Date: Name:
If the measurement devices are queried electronically, for example with a Scout Mobile
Device, entry of the measuring devices in the table can be skipped.
Measuring Devices Type Serial No. Date Used Next Cali-
bration
Due
Movable Components:
Yes: No: Signature:
Date: Name:
If “Yes“, enter the movable component with which the check was performed along with the
with the Serial No. in the table.
Movable components (also test phantoms that are part of the system) are parts that can
be used on different systems).
Component Serial No.
Siemens AG RX63-055.832.02.02.02 POLYDOROS SX/LX
Medical Solutions
04.05 CS PS 211
Page 5 of 10
Cust.-No.: Date: Protocol
OK not n.a.
OK
1 Prerequisites / Notes
1.1 Requirements
1.2 Notes
1.2.1 Safety Information
1.2.1.1 General Safety Information
1.2.1.2 Product-specific Safety Information
1.2.2 Product-specific Remarks
1.2.2.1 Notes Regarding Maintenance
1.2.3 General Remarks
1.2.3.1 Maintenance time / interval
1.2.3.2 Tolerance Data
1.2.3.3 Maximum Torque Values in Nm
1.2.3.4 Explanation of Abbreviations in the Maintenance Certificate
1.2.3.5 DHHS Regulations
2 General Visual Check
2.1 Visual Inspection
SI Checking the cover panels
SI Required operator documents present
SI Checking the cable corrugated hoses
SI Checking the cable corrugated hoses (of mobile components)
SI Checking the radiation protective panels
SI Checking warning labels
Maintenance of component was performed completely:
Signature:
Date: Name:
2.2 Tables and Warning Labels
4 POLYDOROS SX/LX
4.1 Special Requirements
4.2 Inspection and Maintenance
4.2.1 General Information
PM Cleaning
POLYDOROS SX/LX RX63-055.832.02.02.02 Siemens AG
04.05 CS PS 211
Page 6 of 10
Medical Solutions
Protocol Date: Cust.-No.:
OK not n.a.
OK
4.2.2 Generator Control Console
PM Cleaning
4.2.3 Error Log
PM Evaluating the Error Log
4.2.4 Checking the High Voltage Cables
SI Check the shielding on the HV cables.
4.2.5 Replacing the Batteries with PL SX 65/80 with XCU HD Unit, Part No.: 38
27 123
PMP Battery replacement performed (required annually) with the PL SX 65/80
Startup Date / Date of Last Replacement
4.2.6 Direct Technique Radiation Displays
SI Checking the Direct Technique Radiation Displays
4.2.7 Indirect Technique Radiation Displays
SI Checking the Indirect Technique Radiation Displays
4.2.8 IONTOMAT Limit
SI Checking the IONTOMAT Limit
4.2.9 Dose Rate IQ Initial Values
4.2.10 Indirect Technique Dose Rate
QIQ Indirect Technique IQ Initial Values
4.2.11 Direct Technique Dose Rate
QIQ Direct Technique IQ Initial Values
4.2.12 Conditioning the X-Ray Tube(s)
PMA Conditioning the tube(s) (test shots)
PM Check of the max. generator power
4.2.13 IQ Final Test with Indirect Technique
QIQ IQ Final Test
..
DD MM YYYY
4.2.14 IQ Final Test with Direct Technique
QIQ IQ Final Test
4.2.15 IONTOMAT Fields
PM Selecting and checking the sensitivity of the IONTOMAT fields
PM Checking IONTOMAT linearity
Maintenance of component was performed completely:
Signature:
Date: Name:
Siemens AG RX63-055.832.02.02.02 POLYDOROS SX/LX
Medical Solutions
04.05 CS PS 211
Page 7 of 10
Cust.-No.: Date: Protocol
OK not n.a.
OK
5 Final Work Steps
5.2 Inspection and Maintenance
SIE Performing the Ground Wire Check
Maintenance of component was performed completely:
Signature:
Date: Name:
6 Changes to Previous Version
POLYDOROS SX/LX RX63-055.832.02.02.02 Siemens AG
04.05 CS PS 211
Page 8 of 10
Medical Solutions
Protocol Date: Cust.-No.:
Generator
Generator Tables 0
Indirect Technique 0
Tab. 1 Fluoroscopy kV and mA
Fluoro kV mA No fluoro
Prior to conditioning the tube
After conditioning the tube
Direct Technique 0
Tab. 2 Work Station 1
Work Station 1 kV mAs not configured
Prior to conditioning the tube
After conditioning the tube
Tab. 3 Work Station 2
Work Station 2 kV mAs not configured
Prior to conditioning the tube
After conditioning the tube
Tab. 4 Work Station 3
Work Station 3 kV mAs not configured
Prior to conditioning the tube
After conditioning the tube
Tab. 5 Iontomat Fields
Iontomat Fields Left Center Right not configured
Work Station 1 mAs mAs mAs
Work Station 2 mAs mAs mAs
Work Station 3 mAs mAs mAs
Tab. 6 Linearity
Linearity 0.3 Cu 0.6 Cu 0.9 Cu not configured
Work Station 1 mAs mAs mAs
Siemens AG RX63-055.832.02.02.02 POLYDOROS SX/LX
Medical Solutions
04.05 CS PS 211
Page 9 of 10
Cust.-No.: Date: Protocol
Linearity 0.3 Cu 0.6 Cu 0.9 Cu not configured
Work Station 2 mAs mAs mAs
Work Station 3 mAs mAs mAs
POLYDOROS SX/LX RX63-055.832.02.02.02 Siemens AG
04.05 CS PS 211
Page 10 of 10
Medical Solutions
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