Home Blood Pressure Monitor Calibration Form
ADVERTISEMENT
1
2Persons using assistive technology may not be able to fully access information in this file. For assistance, e-mail . Include the web site and filename in your message.
Attention - DO NOT enter patient data on this form if the header does not contain preprinted HALT PKD
ID number, clinical center ID, and visit number.
Participant ID: ______________
Clinical Center: _________
Date of Visit:
/
/
haltid
clinic
month dvm day dvd year dvy
___Form was not completed
:
visit
misfm
Home Blood Pressure Monitor Calibration Form
Form # 36
This form is to be completed by designated personnel at every clinic visit and kept in participant’s research chart.
1. Arm used at today’s visit:
Right
Left
Use the appropriate arm, determined at the screening visit, whenever possible. Otherwise, comment below.
2. Home Blood Pressure Device Used
Home BP Monitor Serial Number
___________________
3. Has the participant smoked or consumed caffeine within the past 30 minutes?
Yes
No
4. Participant Technique: Nurse is to observe the participant measuring his/her own blood pressure in the
usual manner. Check below if each step is done correctly or not. Participant is to record all three BP
readings on the Home BP Log.
Wait >30 Seconds
Technique
Cuff Position
Patient Position
Rest >5 Minutes
Record BP x 3
Between Readings
Correct
Incorrect
5. Does the patient use the proper technique for recording BP?
Yes
No
If no, comment below and retrain participant.
a) Is BP training complete?
Yes
N/A
6. Calibration Test Meter (simultaneous readings):
Time (24 hour)
Systolic
Diastolic
Pulse Rate BPM
Home Monitor
:
CTM
:
Difference
a) Are the measurements < 2 mmHg apart (systolic and diastolic)?
Yes
No (If no, repeat)
Time (24 hour)
Systolic
Diastolic
Pulse Rate BPM
Home Monitor
:
CTM
:
Difference
b) Are the measurements < 2 mmHg apart (systolic and diastolic)?
Yes
No
HALT PKD, Home Blood Pressure Monitor Calibration Form, Form 36
Page 1 of 2
Version 1, 2/10/2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical