Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
Medication Refrigerator
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Sign on FRONT of refrigerator door "Medication only"
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Refrigerator is Clean
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Contains only medications
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Temperature is recorded daily
Waste Storage area
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Doors to storage room are closed and locked at all times
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Lids kept on at all times
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Room is clean and dust free
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No stained ceiling tiles
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Medical waste collection data available
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AC Temperature is maintained
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Door locked always
Waiting Room
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Clean and dust free
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Tissue available
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Hand sanitizer available
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Ceiling tiles without stains
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Cleaning checklist is available
General
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Air vents clean
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Boxes off the floor
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No trash cans overflowing
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No signs of bugs on floor or in overhead lights
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Work area free of food and drink
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Staff know contact time of disinfectant in use
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Equipment clean and dust free
Corrective/Preventive Action Plan
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A corrective/preventive action plan is indicated based on the audit results.
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Follow up audit date if corrective action required
Signature
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Auditor Comments
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Auditor signature
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Director/Manager signature
