Name of Procedure 手术名称 ____________
Procedure Description: (non-patient demo, maintenance, surgical procedure, or other) 过程描述：(如无患者演示，维修，外科手术或其他） ____________
Was patient care or outcome affected: (If yes, how?) 是否影响到患者预后？ ____________
Was the patient on the pump or off the pump? 患者是否体外循环？ ____________
Was the patient heparinized? (If yes, how much?) 患者是否肝素化？ ____________
Was surgical procedure prolonged (If yes, how long?) 手术时间是否被延长？多久？ ____________
Was a back-up method or Intervention needed? 是否应用备用解决方式 (If yes, describe) 是，描述 (If no, how was the case completed?) 不是，手术如何完成？ ____________
Did the unit display an error code or message? (If yes, list) 设备是否显示报错码或其他信息？ ____________
Did another product other than AtriCure contribute to complaint? (If yes, explain) 有对AtriCure其他产品的投诉么？ ____________
How many times has the ASU been used prior to this problem? 这个问题出现前，ASU用过多少次？ ____________
If complaint involves a clamp, how many ablations were performed prior to event? 如果是钳子的问题，事件发生前进行过多少次消融？ ____________
If complaint involves a clip, was clip placed? 如果投诉涉及夹子，是否事前已放置夹子？ ____________
Was a hand-piece being cleaned between ablations? 消融之间是否对钳子进行清理？ ____________
Does patient have thick (10mm), thin, or diseased tissue? 患者是否有厚超过10mm或很薄或病变组织？ ____________