Use this SOP to keep all medical and laboratory equipment clean, functioning properly, maintained according to manufacturer requirements, and supported by complete written records for CalOptima and DHCS Facility Site Review readiness.

📚 Resources Needed

  • The current inventory of medical, laboratory, and specialized equipment

  • Manufacturer instructions and equipment-specific maintenance and calibration requirements

  • Routine inspection, maintenance, calibration, testing, and cleaning records

  • Healthcare Technology Group (HTG) service records, work orders, receipts, and dated inspection stickers

✅ Before You Start

  • Identify every item used to measure or assess a patient's health status or condition.

  • Confirm all equipment is clean and functioning properly.

  • Confirm manufacturer guidelines are onsite, including documentation when calibration is not required.

  • Adopt an annual safety and calibration cycle when manufacturer guidelines are unavailable.

🚀 Tips & Tricks

  • Organize each equipment item's logs, work orders, service receipts, and inspection stickers together.

  • Keep the applicable manufacturer guidance with the record, especially when calibration is not required.

📘 Instructions

Step 1: Keep All Equipment Clean

  • Keep all equipment used to measure or assess a patient's health status or condition clean.

  • Follow and document the established cleaning and testing procedure for every item of specialized equipment.

Step 2: Confirm Equipment Is Functioning Properly

  • Confirm that all equipment used to measure or assess a patient's health status or condition is functioning properly.

  • For any failure or malfunction, follow the repair procedure, retain the repair record, and confirm proper function before returning the equipment to service.

Step 3: Document Routine Maintenance And Specialized Equipment Care

  • Maintain evidence that standard operating procedures were followed for routine inspection and maintenance, calibration, repair of a failure or malfunction, and the testing and cleaning of all specialized equipment.

  • Use appropriate written records, including calibration or other written logs, work orders, service receipts, dated inspection stickers, and other documentation of completed work.

  • Review the records regularly and correct missing or overdue documentation.

Step 4: Follow Manufacturer Guidelines Or HTG Annual Service

  • Maintain all specialized equipment according to the manufacturer's specified guidelines, or have Healthcare Technology Group (HTG), the clinic's qualified technician, service the equipment annually.

  • Keep the manufacturer guidelines and applicable HTG maintenance or annual service documentation onsite.

Step 5: Determine And Document Calibration Requirements

  • Keep manufacturer guidelines onsite when they indicate that calibration is not necessary.

  • If manufacturer guidelines are unavailable, adopt an annual safety and calibration cycle for the equipment.

  • Blood pressure cuffs, monitors, nebulizers, and other related equipment do not need calibration unless the manufacturer requires it.

  • For equipment that does not require calibration, keep the manufacturer guidelines onsite as evidence.

🛠 Troubleshooting

Manufacturer Guidelines Are Not Available

Place the equipment on an annual safety and calibration cycle and document the completed service. Retain the manufacturer guidance when it becomes available.

Equipment Fails Or Malfunctions

Remove the equipment from use, follow the repair procedure, retain the work order or service record, and confirm proper function before returning it to service.

A Required Maintenance Record Is Missing

Obtain appropriate written evidence when possible, such as a log, HTG work order, service receipt, or dated inspection sticker, and correct the recordkeeping process.

✅ Completion Check

  • All equipment used to measure or assess patient health status or condition is clean and functioning properly.

  • Records confirm that routine inspection and maintenance, calibration, repair of failures or malfunctions, testing, and cleaning procedures were followed for all specialized equipment.

  • Written evidence includes the applicable logs, work orders, service receipts, dated inspection stickers, or equivalent documentation.

  • All specialized equipment is maintained under the manufacturer's specified guidelines or serviced annually by Healthcare Technology Group (HTG), the clinic's qualified technician.

  • Manufacturer guidance supports equipment that does not require calibration; equipment without available guidance is placed on an annual safety and calibration cycle.

References

CalOptima Health Facility Site And Medical Record Review Audit Packet: Maintenance Of All Medical And Laboratory Equipment, page 37

Source Protocol Revision: Apr 20, 2026

Internal readiness SOP only; the full CalOptima, DHCS, manufacturer, safety, calibration, and equipment requirements control.