Sample Self Assessment LIFEPAK® 1000 Defibrillator Name
Dept.
Facility Date
Marking “yes” indicates I understand the information provided during the defibrillator training session and know how to: Skill
Yes
No
AED Procedure: Recognize cardiopulmonary arrest. Call for help and start CPR. Press On/Off to turn on the defibrillator. Prepare patient for therapy electrode (hands-free pad) placement according to package directions. Confirm therapy electrode connection to defibrillator. Follow screen messages and voice prompts provided by the defibrillator. Confirm no one is touching patient during analysis.
Shock Advised: Confirm no one is touching the patient prior to pressing the Press the
button.
button then start CPR per screen messages and voice prompts.
No Shock Advised: Resume CPR immediately. Follow screen messages and voice prompts provided by the defibrillator.
Manual Mode: Access and use Manual Mode if authorized.
ECG Mode (optional): Use ECG mode and change the therapy cable to ECG cable. Recognize the “Connect Therapy Electrodes” message and take appropriate action.
Maintenance and Testing: Identify symbols in the readiness display and know what they represent. Identify battery status using the battery indicator. Employee signature
Date
Educator or supervisor
Date
For additional information, please consult the Operating Instructions. Operating Instructions can be found
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(Location)
Comments/References