Sample 4: Proof of Process for Flexible Endoscopes

Sample 4: ‘Proof 0f Process’ For Flexible Endoscopes

Date Scope Cleaned Rinsed Biocide Final Patient Medical Order Number/ by by Rinse Name Records on Item by No. List Batch no. Expiry Date 1st Immerse Temp Sign date Use Time

Sample 4: ‘Proof of Process’ for Flexible Endoscopes 1 Instructions for using Sample 4: ‘Proof of Process for flexible endoscopes’

General instructions:  Use a dark ink pen  Do not use white out  Do not use an eraser  When the sheet is complete, store in a folder. It is suggested that a new folder is to be used for each half year or year. Label the folder and store in a safe, dry place in accordance with the local facility’s established policy.

Date: Date that the endoscope is processed

Endoscope number/item: Utilise this column only if your facility processes more than one flexible endoscope If your facility has more than one flexible endoscope, identify each of them by the serial number, or use a number, letter or colour

Cleaned by: This is for recording the identity of the person who cleaned the flexible endoscope

Rinsed by: This is for recording the identity of the person who rinsed the flexible endoscope after it was cleaned prior to disinfection

Biocide batch number: This is for recording the manufacturer’s batch number of the container of biocide, which is to be used for disinfection of the particular endoscope. (This will remain the same until a particular solution of biocide is changed.)

Biocide expiry date: This is for recording the expiry date, which is stated on the manufacturer’s container from which the biocide solution in use was taken. (This will also remain the same until a particular solution of biocide is changed.)

Biocide date 1st use: This is for recording the date of activation or commencement of use of the biocide solution to be used for endoscope disinfection

Biocide immerse time: This is for recording the period of time during which the endoscope being reprocessed was continuously immersed in the biocide solution

Biocide temp: This is for a record of the temperature of the biocide solution when the endoscope was reprocessed.

Biocide sign: Signature/initial of the person responsible for disinfection of the endoscope

Final rinse by: Sign against the items that are released for future patient use

Patient name or medical records no: Record either the patient’s name or the patient’s medical record number so that there is a link between each processed instrument or tray and the particular patient on which it is used

Order on List: This is for recording the position on the endoscopic procedure list that each particular patient receiving an endoscope(s) processed that day, is located

Sample 4: ‘Proof of Process’ for Flexible Endoscopes 2