Title Page

  • Division/Location

  • Conducted on

  • Prepared by

Patient Room:

  • Employee Name:

  • PT. Room #

  • 1. Overbed Table Cleaned?

  • 2. Night Stand Cleaned?

  • 3. Phone Cleaned?

  • 4. T.V Cleaned free of Dust?

  • 5. Picture Frame free of Dust?

  • 6. Overbed Light Cleaned free of Dust?

  • 7. Closet Cleaned?

  • 8. Walls Cleaned?

  • 9. Vents Cleaned free of Lint?

  • 10. Ceiling Cleaned?

  • 11. Door Cleaned?

  • 12. Door Handle Cleaned?

  • 13. Door Frame Cleaned?

  • 14. Waste Can Cleaned?

  • 15. Floors Cleaned?

  • 16. Cubicle Curtain Cleaned?

  • 17. Cubicle Curtain Functional?

  • 18. Room Organized?

Patient Restroom:

  • 1. Toilet Bowl Cleaned?

  • 2. Sink Cleaned?

  • 3. Shower Cleaned?

  • 4. Shower Curtain Cleaned?

  • 5. Shower Curtain Functional ?

  • 6. Supplies In Place?

  • 7. Floors Cleaned?

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