Discharge Patient Division - E.Q.E. 2018

• Division/Location

• Conducted on

  Date

• Prepared by

Patient Room:

• Employee Name:

• PT. Room #

• 1. Overbed Table Cleaned?

  Yes

  No

  N/A

• 2. Night Stand Cleaned?

  Yes

  No

  N/A

• 3. Phone Cleaned?

  Yes

  No

  N/A

• 4. T.V Cleaned free of Dust?

  Yes

  No

  N/A

• 5. Picture Frame free of Dust?

  Yes

  No

  N/A

• 6. Overbed Light Cleaned free of Dust?

  Yes

  No

  N/A

• 7. Closet Cleaned?

  Yes

  No

  N/A

• 8. Walls Cleaned?

  Yes

  No

  N/A

• 9. Vents Cleaned free of Lint?

  Yes

  No

  N/A

• 10. Ceiling Cleaned?

  Yes

  No

  N/A

• 11. Door Cleaned?

  Yes

  No

  N/A

• 12. Door Handle Cleaned?

  Yes

  No

  N/A

• 13. Door Frame Cleaned?

  Yes

  No

  N/A

• 14. Waste Can Cleaned?

  Yes

  No

  N/A

• 15. Floors Cleaned?

  Yes

  No

  N/A

• 16. Cubicle Curtain Cleaned?

  Yes

  No

  N/A

• 17. Cubicle Curtain Functional?

  Yes

  No

  N/A

• 18. Room Organized?

  Yes

  No

  N/A

Patient Restroom:

• 1. Toilet Bowl Cleaned?

  Yes

  No

  N/A

• 2. Sink Cleaned?

  Yes

  No

  N/A

• 3. Shower Cleaned?

  Yes

  No

  N/A

• 4. Shower Curtain Cleaned?

  Yes

  No

  N/A

• 5. Shower Curtain Functional ?

  Yes

  No

  N/A

• 6. Supplies In Place?

  Yes

  No

  N/A

• 7. Floors Cleaned?

  Yes

  No

  N/A