Title Page

  • Conducted on

  • Auditors

  • Ward/ Department

  • Overall findings


  • Number of Physician

  • Number of Nurses

  • Number of PCA

  • Number of House Keepers

  • Number of Porters

  • Number of Clerks

  • Students

  • Other Workers


  • Unit/area specific policy manual

  • Nursing policy manual

  • Staff Orientation manual

  • Infection Control manual

  • Equipment/Service Manual

  • Procedural Guidelines

  • Clinical practice guidelines

  • Occupational Health and Safety Guidelines

  • Do managers, supervisors and employees have a clear understanding of their roles and responsibilities

  • Staff knowledgeable about management of spills


  • Blood, bodily fluid exposure management posted

  • Hazardous chemical: labels and MSDSs

  • Restricted area

  • Fire exits

  • Evacuation routes

  • Isolation signs

  • Wet Floor

  • Eye wash stations (e.g. lab, chemical storage areas)

  • Instruction for use of Personal Protective Equipment

  • Noise protection required

  • Bio-hazard areas

  • Radiation area

  • Hand Hygiene posters


  • Staff of the unit are aware of the key concepts contained in the manual

  • The ward sister/charge nurse/team leader is aware of their role and responsibility in relation to infection prevention and control (IPC)

  • Within the unit, there is a lead person responsible for IPC


  • There is adequate Eqiupment for hand hygiene

  • Paper towels are available at all hand washing sinks

  • Soap available in dispensers

  • Adequate Hot water available

  • Adequate cold water available

  • Sinks clean and well maintained

  • Wash hand sinks present in dirty utility/ sluice room

  • Sinks present in clean room

  • Clean and dirty sink identified

  • Soap Hand sanitizer and towel dispensers clean & in good working order

  • Staff knowledgeable about hand hygiene procedure

  • Staff aware of the 5 moments of hand hygiene

Environmental Cleaning and disinfection

  • Cleaning schedule available and accessible

  • Check list available and completed

  • Cleaning and sanitizing done at least twice per day

  • Patient immediate environment clean and sanitize after each use

  • Staff aware of the cleaning and sanitizing procedure

  • Disinfectant use is the correct concentration

  • Reusable cleaning cloth washed, disinfected and allowed to dry after use

  • High touch areas are cleaned at least every two hours

Procedure for handling infectious cases

  • Are infectious (MDRs) cases reported as class 1 notifiable disease

  • Are dedicated equipment used on these patients

  • Are equipment cleaned and disinfected after each use

  • Are Protocols for contact, droplet and airborne precautions adhered to


  • Proper management of clean linen

  • Proper management of soil and contaminated linen


  • Proper storage

  • Not Expired

  • Date and time of multi vial medication indicated

  • Safe Injection Practices

  • Storage temperature for medication appropriate

  • Storage temperature refrigerator logged

  • No food present in medication refrigerator

  • Medication refrigerator clean & in good working order

Suitable Personal Protective Equipment; Adequate Supplies of:

  • N95 respirator available and in adequate amount

  • Protective eye wear available and in adequate amount

  • Impermeable gowns available and in adequate amount

  • Workers trained in donning and doffing of PPE

  • Disposable gowns available and in adequate supply

  • Respirator available for handling chemicals

  • Surgical Masks available and in adequate amount


  • Furniture in good condition (can be easily cleaned)

  • Refrigerator temperature recorded & Maintained

  • Refrigerator clean and in good working condition

  • Personal Items neatly placed

  • Nurses station clean and tidy

  • Isolation room appropriately ventilated

  • Is there patient call system in the unit/functional

  • Are patient aware of the system

  • Does staff respond to alarms/buzzers

  • No damaged or broken beds, stretchers, Wheel Chair/tables/lockers/mattresses

  • Handrails/grab bars in bathroom

  • non skid tiles/bath boards in shower

  • Is there standard spacing between patients > or = to 3ft

Equipment Procedure

  • Autoclave clean & in good working condition

  • Frequent Microbiological testing

  • Microwave clean & in good working order

  • Glucometer, oximeters, monitoring equipment clean

  • Patient lift available, maintained & clean

  • Bedpan flusher/sterilizers clean and in good working condition

  • Oxygen Cylinder storage appropriate

  • Dialysis machines cleaned and sanitized and maintained according to manufacturer

  • Cleaning procedure adhered to as per protocol & schedule available

  • Guarding safety device in place

  • Start/stop switches clearly marked and easy to reach

  • Safe operating procedure available

  • Lockout procedure available

  • Training given in safe use of tools and machinery

  • Manufacturer's manuals available for all tools and machinery

  • Are reusable devices/equipment handled according to guidelines


  • Sharps disposal at point-of-use

  • Sharps container not more than 3/4 full

  • Sharps container appropriate

  • Safety Engineered needles available

  • Sharps containers elevated



  • Written bio-hazardous waste protocol present

  • Written regular waste disposal protocol present

  • Appropriately label containers/bag for waste

  • Waste bins not more than 3/4 full and in good working condition

  • Waste segregation adhere to



  • Schedule cleaning for water storage tank

  • Residual chlorine present in tap water

  • Chlorine residual reading

  • Plumbing Fixture clean and in good working condition

  • Air Conditioning unit clean and in good working condition


  • Suitable ergonomics chairs available

  • Foot rest provided for desk

  • Countertops & Work station at appropriate height & adjustable

  • Ergonomic lifting device available

  • Store heavy items at waste height


Physical Environment

  • Floor slip-proof

  • Floor, walls, doors, and ceiling clean & intact

  • Floor & doorway clear and free of obstructions

  • Good drainage for spills

  • Changes in floor level clearly marked

  • No mold or fungus

  • No cords on floors & other tripping hazards

  • Shelves present and adequate to support material

  • Steps appear safe and in good condition

  • Rails intact and in place

  • Ramps for disable present

  • Adequate storage space available

  • FIFO praciced


  • Lighting adequate, maintained

  • Task specific lighting present where appropriate

  • Natural lighting adequate

  • Emergency lighting provided and Maintained

  • Electrical outlets intact

  • Outlets sufficient to avoid overloading


  • Minimum 12 total air changes per <br> hour

  • Minimum 3 air changes of outdoor <br>air per hour

  • Negative pressure in Isolation areas, autopsy suite

  • Positive pressure in operating room

  • Mechanical ventilation for hazardous emissions such as sterilizing chemicals

  • Temperature Satisfactory

  • Relative Humidity Satisfactory

  • CO2 satisfactory

  • MO satisfactory

  • VOC Satisfactory

Exhaust Fume Hood

  • Physical integrity satisfactory

  • Signs of blockage

  • Unusual Noise


  • Type of Filters satisfactory

  • Filter efficiency satisfactory

  • Filter clean

  • Signs of by passing

  • Change out schedule

Duct Work

  • Physical integrity satisfactory

  • Dryness & Cleanliness satisfactory

  • Signs of blockage from static pressure

  • Air balancing records

Reheat Coils/Mixing Boxes

  • Dryness & Cleanliness Satisfactory

  • VAV(Variable air volume) calibration set for at least minimum

  • Required outside air delivery at all times

HVAC Equipment( e.g. Heating/cooling units, stacks and condensers)

  • Physical integrity

  • Dryness & Cleanliness satisfactory

  • No slime, mold, dirt bird dropping, soot accumulation

  • Integrity & cleanliness of chamber floor, wall and ceiling

  • Cleanliness & operation of various components satisfactory


  • Type & Location appropriate

  • Set appropriately

  • Access controlled

Air Conditioning Unit (non HVAC)

  • AC clean and in good working in condition

  • Temperature within acceptable standards

  • Cleaning schedule available for the unit


  • Emergency exits visible

  • Emergency exit free from obstruction

  • Emergency evacuation plan posted

  • Fire extinguishers present

  • Fire extinguishes regularly inspected

  • Fire Protection equipment (e.g hoses) accessible & maintained

  • Clear access to electrical panels/no combustible material stored

  • Sockets in good condition

Staff Areas: Clean and Orderly Appearance, enough room to work

  • Staff lockers/change area accessible and available

  • Staff lounge present & clean with no medical supplies or device

  • Staff toilet clean

  • Refrigerator in good working condition

  • Furniture/office equipment secure from tripping: appropriate work being done

  • Treatment room

  • Equipment storage

  • Work areas(e.g.lab benches, maintenance rooms

  • Containers with proper lids

Sewage Manaagement

  • Signage place on lavatory door

  • Toilet clean and in good working codition


  • Proper and adequate storage space

  • Proper label

  • MSDS available


  • Manager

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.