Technical Specs Part 3

1
4
2
Da
te:__________ Center:________
_ Patient Code:____________
Patient name:________
___________________________
_______
Pump Label:
Catheter Label:
PPC Lab
el:
Insulin Lot Number:__
_______
Communica
tor-settings:
P
atient Communicator ID:______
__ Supervisor Code:_________
Max meal bolus:_____
___U Max basal rate:_______
_____U/h
Maximums
(locked/unlocked):______ Alar
m feedback "ON":__
Basal rate programmed with PPC
:________U/h
W
eight of full "IN 2" syringe befo
re filling the
reservoir:___________
__________g (1)
Weight of f
ull "IN 2" syringe after filling the
reservoir and remov-
i
ng 2ml from the pump:________
__________ g (2)
Total amount placed i
n the reservoir (1-2):__________
_______ g
Verification
of alarm feedback: yes / no
Time delivery started, priming b
olus:_____________
Calculated stroke vol
ume:
a) number
of strokes delivered:__________
______
b) total volume delivered:_____
____________
c) calculated stroke v
olume (b/a):__________
Verific at io
n of the delivery from the cathe
ter tip: yes / no
Date:_____________ Surgeo
n name:____________________
_
Anesthesia:_______
_____________ Pocket depth:_
________cm
Catheter
fixation:________________ Pum
p fixation:__________
Catheter type:_____________
__ Pump type:_____________
__
Pump orientation: Complic
ations:
MiniMed Implant Worksheet
Dmp9196021-011_c.book Page 142 Wednesday, April 3, 2002 5:06 PM