COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :…………Phoøng
moå………………………………………………………………….
Ngaøy(Date) : …………………………………………/………/…
201…………………………………………………………..
Thieát bò(Equipment) : Monitor theo doõi beänh nhaân(Patient Monitor)
Haõng SX(Manufacturer) : BENNETT Model : NPB400 SN :
96A
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit and 
accessories) : SpO2 Sensor, ECG cable,
Power cable
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra chöùc naêng baùo ñoäng(Check 
alarms)
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check battery 
chaging)
Kieåm tra boä phaän ño huyeát aùp(Check 
NIBP)
Kieåm tra boä phaän ño ECG(Check ECG) 
Kieåm tra Sensor SpO2 (Check SpO2 
Sensor)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
 …………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : X-Quang C-Arm(X-ray C-Arm)
Haõng SX(Manufacturer) : GE Model : STENOSCOP D6 SN :
93/11044/03
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit and 
accessories)
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra maøn hình 1(Check monitor 1) 
Kieåm tra maøn hình 2(Check monitor 2) 
Kieåm tra ñaàu ñeøn(Check tube) 
Kieåm tra caùp cao theá(Check HV 
cable)
Kieåm tra thuøng cao theá(Check HV 
tank)
Kieåm tra maïch chính(Check main 
board)
Kieåm tra ñeøn gom tia(Check 
Collimator)

Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : Gaây meâ, giuùp thôû (Ventilators)
Haõng SX(Manufacturer) : ACOMA Model : PH-3F SN :
18594
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Caøi ñaët caûnh baùo(Alarm 
settings)
Thoâng soá beänh 
nhaân(Patient Data)
Ñieàu chænh aùp 
suaát(Pressure Volume)
Löu löôïng Oxy(% O2) 
Cheá ñoä hoaït ñoäng(Active
Mode): VCV-A/C 
Kieåm tra maøn hình(Check 
Monitor)
Kieåm tra Boä nguoàn
chính(Check Mains Power) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046
 PHIEÁU BAÛO TRÌ THIEÁT BÒ
(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : Gaây meâ(Anesthesia)
Haõng SX(Manufacturer) : SOFTLANDER Model : SL180 SN :
9804003
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Ñieàu chænh aùp 
suaát(Pressure Volume)
Löu löôïng Oxy(% O2) 

Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng
 COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ
TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………Caáp
cöùu……………………………………………………………….
Ngaøy(Date) : …………………………/…………/…
201………………………………………………………………………..
Thieát bò(Equipment) : SOÁC TIM(Cardiogenic shock)
Haõng SX(Manufacturer) : FUKUDA Model : FC 560I SN :
29112204
Danh muïc baûo trì Ñaõ thöïc Keát Quaû Ghi Chuù
(Maintenance items) hieän (Result) (Remarks)
(Done)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit 
and accessories)
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra chöùc naêng baùo
ñoäng(Check alarms) 
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check
battery chaging) 
Kieåm tra boä phaän ño 
ECG(Check ECG)
Kieåm tra rô-le cao theá(Check HV 
Relay)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : Phoøng Khaùm Ña Khoa Quoác teá Columbia
ASIA Saøi Goøn
Khoa/Phoøng(Department) :……………Caáp
cöùu……………………………………………………………….
Ngaøy(Date) : …………………………/…………/…
201………………………………………………………………………..
Thieát bò(Equipment) : SOÁC TIM(Cardiogenic shock)
Haõng SX(Manufacturer) : PHILIPS Model : SMART SN :US00466597
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra chöùc naêng baùo
ñoäng(Check alarms) 
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check
battery chaging) 
Kieåm tra boä phaän ño
ECG(Check ECG) 
Kieåm tra rô-le cao theá(Check
HV Relay) 
Kieåm tra maùy in(Check 
Printers)
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : NOÄI SOI(ENDOSCOPY) CTC
Haõng SX(Manufacturer) : OLYMPUS Model : OCS-3 SN :
805025
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra Camera(Check 
Camera)
Kieåm tra maùy in(Check 
Printers)
Kieåm tra maøn hình(Check 
Monitor)
Kieåm tra Boä nguoàn(Check
Mains Power) 
Kieåm tra boä ñieàu chænh
kính(Adj the microscope) 
Kieåm tra Cable quang(Fiber 
Optic test)
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : Phoøng Khaùm Ña Khoa Quoác teá Columbia
ASIA Saøi Goøn Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : NOÄI SOI(ENDOSCOPY)
Haõng SX(Manufacturer) : OLYMPUS Model : OEV-202 SN :
1700670
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra Camera(Check 
Camera)
Kieåm tra maùy in(Check 
Printers)
Kieåm tra maøn hình(Check 
Monitor)
Kieåm tra Boä nguoàn(Check
Mains Power) 
Kieåm tra boä ñieàu chænh
kính(Adj the microscope) 
Kieåm tra Cable quang(Fiber
Optic test) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)
 Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : NOÄI SOI(ENDOSCOPY)
Haõng SX(Manufacturer) : SNOWDEN PENCER Model : 89-8700 SN :
094101
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra Camera(Check 
Camera)
Kieåm tra maùy in(Check 
Printers)
Kieåm tra maøn hình(Check 
Monitor)
Kieåm tra Boä nguoàn(Check
Mains Power) 
Kieåm tra boä ñieàu chænh
kính(Adj the microscope) 
Kieåm tra Cable quang(Fiber
Optic test) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
 Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : HUÙT MÔÕ(Liposuction Machine)
Haõng SX(Manufacturer) : EXONIX Model : SN :
00971002
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Coâng suaát sieâu 
aâm(Untrasonic Power)
Boä Ñieàu nhieät(Temprature 
Controller)
Bôm huùt 
 Baøn ñieàu khieån(Consoles) 
Kieåm tra Boä nguoàn
chính(Check Mains Power) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : ÑEØN MOÅ(SURGICAL LIGHTS)
Haõng SX(Manufacturer) : CHOMOPHARE Model : C-450 SN :
2030N99F1935
Danh muïc baûo trì Ñaõ thöïc Keát Quaû Ghi Chuù
(Maintenance items) hieän (Result) (Remarks)
(Done)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit 
and accessories)
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra Boä nguoàn chính(Check
Mains Power) 
Boä ñieàu chænh ñeøn 1(Sourc Adj 
Lights 1)
Boä ñieàu chænh ñeøn 2(Sourc Adj 
Lights 2)
Ñieàu chænh caân baèng nhaùnh 
1
Ñieàu chænh caân baèng nhaùnh 
2

Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
 Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : ÑEØN MOÅ(SURGICAL LIGHTS)
Haõng SX(Manufacturer) : CHOMOPHARE Model : C-571 SN :
2370N99F13853
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of main 
unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra Boä nguoàn
chính(Check Mains Power) 
Boä ñieàu chænh ñeøn 1(Sourc 
Adj Lights 1)
Boä ñieàu chænh ñeøn 2(Sourc 
Adj Lights 2)
Ñieàu chænh caân baèng nhaùnh 
1
Ñieàu chænh caân baèng nhaùnh 
2

Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)
 Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : NOÀI HAÁP (Autoclaves Machine)
Haõng SX(Manufacturer) : Myõ Model : KSG-116 SN :
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra Boä nguoàn(Check
Mains Power) 
Bôm nöôùc(Water Pump) 
Ñieän trôû ñun(Heat 
Resistances)
Boä phaän tieät 
truøng(Sterilization)
Boä phaän saáy(Dried Parts) 

Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Phoøng
moå……………………………………………………….
Ngaøy(Date) : ………………………………………/…………/…
201…………………………………………………………..
Thieát bò(Equipment) : KÍNH HIEÅN VI(Microscope)
Haõng SX(Manufacturer) : OLYMPUS Model : OME-1000 SN :
802004
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra Boä nguoàn
chính(Check Mains Power) 
Boä ñieàu chænh kính(Adj the
microscope) 
Boä ñieàu chænh caân baèng 
 Nguoàn saùng(Sourc Adj 
Lights)
Veä sinh, lau kính(Clean Glass) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :………………Hoài
söùc…………………………………………………………….
Ngaøy(Date) : …………………………………………/……………/…
201……………………………………………………..
Thieát bò(Equipment) : Monitor theo doõi beänh nhaân(Patient Monitor)
Haõng SX(Manufacturer) : BENNETT Model : NPB400
SN : 96
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit and 
accessories) : SpO2 Sensor, ECG cable,
Power cable
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra chöùc naêng baùo ñoäng(Check 
alarms)
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check battery 
chaging)
Kieåm tra boä phaän ño huyeát aùp(Check 
NIBP)
Kieåm tra boä phaän ño ECG(Check ECG) 
Kieåm tra Sensor SpO2 (Check SpO2 
Sensor)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
 Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :……………………Hoài
söùc……………………………………………………….
Ngaøy(Date) : …………………………………/…………………/…
201………………………………………………………..
Thieát bò(Equipment) : Monitor theo doõi beänh nhaân(Patient Monitor)
Haõng SX(Manufacturer) : BENNETT Model : NPB400 SN :
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks
(Done) (Result) )
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit and 
accessories) : SpO2 Sensor, ECG cable,
Power cable
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra chöùc naêng baùo ñoäng(Check 
alarms)
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check battery 
chaging)
Kieåm tra boä phaän ño huyeát aùp(Check 
NIBP)
Kieåm tra boä phaän ño ECG(Check ECG) 
Kieåm tra Sensor SpO2 (Check SpO2 
Sensor)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng
 COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ
TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :………………Hoài
söùc…………………………………………………………….
Ngaøy(Date) : …………………………………………/……………/…
201……………………………………………………..
Thieát bò(Equipment) : Monitor theo doõi beänh nhaân(Patient Monitor)
Haõng SX(Manufacturer) : BENNETT Model : NPB400 SN :
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit and 
accessories) : SpO2 Sensor, ECG cable,
Power cable
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra chöùc naêng baùo ñoäng(Check 
alarms)
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check battery 
chaging)
Kieåm tra boä phaän ño huyeát aùp(Check 
NIBP)
Kieåm tra boä phaän ño ECG(Check ECG) 
Kieåm tra Sensor SpO2 (Check SpO2 
Sensor)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
 Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :………………X-
Quang…………………………………………………………….
Ngaøy(Date) : …………………………………………/……………/…
201……………………………………………………..
Thieát bò(Equipment) : Máy chụp X-Quang cao tần
Haõng SX(Manufacturer) : TOSHIBA Model : KXO-32S SN :
K2B12X2148
Danh muïc baûo trì Ñaõ thöïc Keát Quaû Ghi Chuù
(Maintenance items) hieän (Result) (Remarks)
(Done)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of main 
unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra Bucky bàn(Check Table 
Bucky )
Kieåm tra Bucky đứng(Check Wall 
Bucky )
Kieåm tra ñaàu ñeøn(Check tube) 
Kieåm tra caùp cao theá(Check HV 
cable)
Kieåm tra thuøng cao theá(Check 
HV tank)
Kieåm tra maïch chính(Check 
main board)
Kieåm tra ñeøn gom tia(Check 
Collimator)
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks. Phaïm
Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :…………X-
Quang………………………………………………………………….
Ngaøy(Date) : …………………………………………/……………/…
201……………………………………………………..
Thieát bò(Equipment) : Hệ thống xử lí hình ảnh X-Quang Kỹ thuật số CR
 Haõng SX(Manufacturer) : KONICA Model : Regius 110HQ SN :
040408142
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Vệ sinh tấm REGIUS Plate(Clean 
REGIUS Plate)
Vệ sinh Cassette Insertion Slot(Clean 
Cassette Insertion Slot)
Vệ sinh bộ lọc gió(Clean Air Intake) 
Kiểm tra đèn xóa Halogen(Check Erase 
Lamp)

Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt Kyõ
Sö Baûo Trì
(Sign & full name) (User) (Supervisor) (Engineer)

Ks. Phaïm
Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046
 PHIEÁU BAÛO TRÌ THIEÁT BÒ
(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : BV Quoác teá Columbia ASIA Gia Ñònh
Khoa/Phoøng(Department) :…………X-
Quang………………………………………………………………….
Ngaøy(Date) : …………………………………………/……………/…
201……………………………………………………..
Thieát bò(Equipment) : Máy in Films X-Quang
Haõng SX(Manufacturer) : KONICA Model : Dry Pro 873 SN : 09932240
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of 
main unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Veä sinh khay đựng phim(Clean 
Film ejection tray)
Veä sinhkhay load phim(Clean 
suply tray)
Veä sinh khe lọc gió(Clean 
Intakes/outlets)
Veä sinh Roller load phim(Clean 
Roller)
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt Kyõ
Sö Baûo Trì
(Sign & full name) (User) (Supervisor) (Engineer)

Ks. Phaïm
Thaønh Höng
 COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ
TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : Bệnh Viện Quận 3
Khoa/Phoøng(Department) :………………X-
Quang…………………………………………………………….
Ngaøy(Date) : …………………………………………/……………/…
201……………………………………………………..
Thieát bò(Equipment) : Máy chụp X-Quang thường qui
Haõng SX(Manufacturer) : INFINITY Model : 325D SN :
Danh muïc baûo trì Ñaõ thöïc Keát Quaû Ghi Chuù
(Maintenance items) hieän (Result) (Remarks)
(Done)
Veä sinh maùy chính vaø caùc
phuï kieän(Clean exterior of main 
unit and accessories)
Kieåm tra hoaït ñoäng
maùy(Check functions of 
equipment)
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra Bucky bàn(Check Table 
Bucky )
Kieåm tra Bucky đứng(Check Wall 
Bucky )
Kieåm tra ñaàu ñeøn(Check tube) 
Kieåm tra caùp cao theá(Check HV 
cable)
Kieåm tra thuøng cao theá(Check 
HV tank)
Kieåm tra maïch chính(Check 
main board)
Kieåm tra ñeøn gom tia(Check 
Collimator)
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
 Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : Bệnh viện Quận 3
Khoa/Phoøng(Department) :……………Phòng khám…………………………………………
Ngaøy(Date) : …………………………/…………/…
201………………………………………………………………………
Thieát bò(Equipment) : ĐO ĐIỆN TIM(Cardiofax)
Haõng SX(Manufacturer) : Model : SN :
Danh muïc baûo trì Ñaõ thöïc Keát Quaû Ghi Chuù
(Maintenance items) hieän (Result) (Remarks)
(Done)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit 
and accessories)
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check
battery chaging) 
Kieåm tra boä phaän ño 
ECG(Check ECG)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
 Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : Bệnh viện Quận 3
Khoa/Phoøng(Department) :……………Caáp cöùu……………………………………………………
Ngaøy(Date) : …………………………/…………/…
201………………………………………………………………………
Thieát bò(Equipment) : ĐO ĐIỆN TIM(Cardiofax)
Haõng SX(Manufacturer) : NIHONKOHDEN Model : SN :
Danh muïc baûo trì Ñaõ thöïc Keát Quaû Ghi Chuù
(Maintenance items) hieän (Result) (Remarks)
(Done)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit 
and accessories)
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi
ñaët(Check the settings) 
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check
battery chaging) 
 Kieåm tra boä phaän ño 
ECG(Check ECG)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ngöôøi söû duïng Boä phaän Giaùm saùt
Kyõ Sö Baûo Trì
(User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : Bệnh viện Quận 3
Khoa/Phoøng(Department) :………………Phòng Mổ………………………………………………
Ngaøy(Date) : …………………………………………/……………/…
201……………………………………………………..
Thieát bò(Equipment) : Monitor theo doõi beänh nhaân(Patient Monitor)
Haõng SX(Manufacturer) : NIHONKOHDEN Model : SN :
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit and 
accessories) : SpO2 Sensor, ECG cable,
Power cable
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra chöùc naêng baùo ñoäng(Check 
alarms)
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check battery 
chaging)
Kieåm tra boä phaän ño huyeát aùp(Check 
NIBP)
Kieåm tra boä phaän ño ECG(Check ECG) 
Kieåm tra Sensor SpO2 (Check SpO2 
Sensor)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng

COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ

TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
 Teân beänh vieän(Hospital) : Bệnh viện Quận 3
Khoa/Phoøng(Department) :………………Cấp
Cứu…………………………………………………………….
Ngaøy(Date) : …………………………………………/……………/…
201……………………………………………………..
Thieát bò(Equipment) : Monitor theo doõi beänh nhaân(Patient Monitor)
Haõng SX(Manufacturer) : NIHONKOHDEN Model : SN :
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit and 
accessories) : SpO2 Sensor, ECG cable,
Power cable
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra chöùc naêng baùo ñoäng(Check 
alarms)
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check battery 
chaging)
Kieåm tra boä phaän ño huyeát aùp(Check 
NIBP)
Kieåm tra boä phaän ño ECG(Check ECG) 
Kieåm tra Sensor SpO2 (Check SpO2 
Sensor)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng
 COÂNG TY CP TRANG THIEÁT BÒ KYÕ THUAÄT Y TEÁ
TP.HCM
MEDICAL TECH NICAL SERVICES HCM CITY JOINT STOCK COMPANY
252-254 Coáng Quyønh – Quaän 1 – TP.HCM
ÑT : 38390996 – Fax : (84.8)38334046

PHIEÁU BAÛO TRÌ THIEÁT BÒ

(MAINTENANCE FORM)
Teân beänh vieän(Hospital) : Phoøng Khaùm Ña Khoa Quoác teá Columbia
ASIA Saøi Goøn Khoa/Phoøng(Department) :
………………………………………………………………………………………….
Ngaøy(Date) : …………………………………………/………/…
201…………………………………………………………..
Thieát bò(Equipment) : Monitor theo doõi beänh nhaân(Patient Monitor)
Haõng SX(Manufacturer) : PHILIPS Model : SN :
Danh muïc baûo trì Ñaõ thöïc Keát Ghi Chuù
(Maintenance items) hieän Quaû (Remarks)
(Done) (Result)
Veä sinh maùy chính vaø caùc phuï
kieän(Clean exterior of main unit and 
accessories) : SpO2 Sensor, ECG cable,
Power cable
Kieåm tra hoaït ñoäng maùy(Check
functions of equipment) 
Kieåm tra caùc thoâng soá caøi 
ñaët(Check the settings)
Kieåm tra chöùc naêng baùo ñoäng(Check 
alarms)
Kieåm tra pin (Check battery) 
Kieåm tra maïch saïc pin(Check battery 
chaging)
Kieåm tra boä phaän ño huyeát aùp(Check 
NIBP)
Kieåm tra boä phaän ño ECG(Check ECG) 
Kieåm tra Sensor SpO2 (Check SpO2 
Sensor)
Kieåm tra maùy in(Check Printers) 
Keát luaän :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….
 Ñeà nghò :
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………………………………….

Kyù teân Ngöôøi söû duïng Boä phaän Giaùm saùt

Kyõ Sö Baûo Trì
(Sign & full name) (User) (Supervisor)
(Engineer)

Ks.
Phaïm Thaønh Höng