Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Nursing Stations

  • 1. Clean and free of clutter

  • 2. No food present, Only drinks with a lid.

  • 3. Use of hospital-approved hand lotion.

  • 4. No patient care supplies left open on tables.

  • 5. Trash is not overflowing.


  • 1. Hand hygiene is being performed correctly.

  • 2. No fingernail polish or artificial nails. (If providing patient care)

  • 3. Appropriate fingernail length. (1/4")

  • 4. Staff understands isolation precaution protocol and needlestick protocol.

Waiting Room, Public Bathrooms, and Hallways

  • 1. All horizontal surfaces are clean

  • 2. Areas/hallways are not cluttered.

  • 3. Trash is not overflowing.

  • 4. Bathrooms are clean.

  • 5. Handwashing supplies are available.

  • 6. No stained ceiling tiles.

Hand Hygiene

  • 1. Sinks for handwashing are appropriately stocked with soap, paper towels, and trash cans.

  • 2. Alcohol hand-rubs are available near patient rooms/in patient rooms and other areas as needed.

  • 3. Hand Hygiene is monitored for staff compliance.

  • 4. Gloves are stocked in patient's room for staff use when needed.


  • 1. PPE supplies are available.

  • 2. Appropriate signage in place.

  • 3. Trash and linen handled per policy.

  • 4. Patient and family given appropriate education.

  • 5. If Airborne precautions, is the door closed.

  • 6. Appropriate PPE being used by staff.

  • 7. Isolation stations being utilized and are stocked.

Soiled Utility

  • 1. Door to room is labeled.

  • 2. Biohazard symbol on door if biomedical waste in room.

  • 3. Soiled linen in hamper with impervious liner.

  • 4. Clean supplies not in room.

  • 5. Appropriate PPE available.

  • 6. Soiled linen covered for transport.

Storage Room

  • 1. Is there a clear walk way.

  • 2. All equipment is clean and stored off the ground.

  • 3. Equipment bins (blue bins) are clean.

  • 4. No tape peeling on the floor.

  • 5. Equipment/supplies are not out of date.

Clean Utility

  • 1. Door to room is labeled.

  • 2. Environment is clean.

  • 3. Clean equipment is tagged/bagged and ready for use.

  • 4. No supplies stored under sink.

  • 5. All supplies off the floor.

Clean Linens

  • 1. Linens are in good condition.

  • 2. Stored on covered cart or in linen room where shelf is covered.

  • 3. Clean linen covered during transport.


  • 1. Daily temperature checks are documented appropriately.

  • 2. Items are appropriately labeled and nothing out of date.

  • 3. Refrigerator is clean.

Patient care equipment

  • 1. Equipment is cleaned according to policy/company recommendations.

  • 2. Glucometer wiped down and using Super Sani-Cloths (purple top) and left to dry for at least 2 minutes before being used again.

  • 3. Vital sign machines are cleaned using the disinfectant wipes before being used.

  • 4. Equipment that has expiration dates have not expired.

  • 5. Telemetry electrodes are dated when they are opened. If expired they are thrown away.

Hazardous Materials and Medical Waste

  • 1. Appropriate sharps container in use.

  • 2. Sharps containers no more than 3/4 full.

  • 3. Sharps containers secured for transport.

  • 4. Appropriate biomedical waste manifests maintained.


  • 1. All cylinders (oxygen , other compressed gas) are secured

  • 2. Empty oxygen tanks are kept separate from full oxygen tanks

  • 3. Fire extinguishers not obstructed from easy access

  • 4. No electrical panels are blocked

  • 5. Hospital furnishings/equipment are kept in good repair (No torn or soiled furniture, wheelchairs, mattresses)

  • 6. Countertops/doors are in good condition with no chipping to laminate

  • 7. No supplies stored under sinks

  • 8. Paper is not present on fire-rated doors

  • 9. Maintains the integrity of egress throughout unit

  • 10. No space heaters present in patient care areas

  • 11. There is at least 18" of open space maintained below a sprinkler deflector to the top of storage

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.