Information

  • Clinic Name

  • Conducted on

  • Prepared by

  • Personnel involved

  • Address
  • Lights are free of dust/bugs?

  • Staff can speak to the correct consent signing process?

  • Reception areas are neat?

  • The window sills are not cluttered and are dust free?

  • All sinks and toilets are clean, soap and towels are available?

  • Floors are clean, free of trash and boxes on floors?

  • Housekeeping closets/Storage are clean and chemicals are stored properly?

  • Linen has no stains and/or tears?

  • Patient privacy curtains are clean, hung properly, function properly, and free of defects? (Cleaned every 12 months)

  • No items are stored under sink?

  • Bottom shelves have 6" clearance for cleaning?

  • Furniture is clean & in good repair (clinical & visitor areas)?

  • Treatment rooms are clean, organized and neat?

  • Equipment is clean and intact (including mats, bolsters, exercise equipment, etc.)?

  • Staff follow CDC hand hygiene?

  • PPE is clean and orderly?

  • Only approved disinfectants in use?

  • Dirty equipment is not stored in clean utility and clean equipment is not stored in dirty utility room?

  • There is no eating or drinking in patient care or public areas?

  • Staff know the process for reporting a work place exposure or injury?

  • Current infectious disease screening process in place?

  • Multi-use containers are correctly labeled and tongue depressors in use when appropriate?

  • There are no expired supplies, medications, or food items?

  • Refrigerators and freezers are labeled properly as to contents?

  • There is no medication or patient food items stored in staff refrigerator?

  • Pantry is clean and items stored properly (ice machine, drawers, cupboards)

  • Sharp boxes are no more than 3/4 full?

  • Biohazard containers are covered and not overflowing?

  • Staff know where spill kits are located?

  • Staff know the wet times (kill time) for the disinfectant wipes used?

  • Additional Comments

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.