Checklist: Patient Room

• Document No.

• Audit Title:

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Cleaning Audit

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Bed

• Floor

• Bathroom

• Personnel

• Date & Time

  Date

• Name:

• Bathroom
  Floor
  Cove Base
  Shower/Bath
  Toilet
  Walls
  Ceiling Vent
  Fixtures
  Dispenser Stocked
  Mirror Clean

Bathroom

Bathroom

• Floor

• Cove Base

• Shower/Bath

• Toilet

• Walls

• Ceiling Vent