Title Page

  • Division/Location

  • Conducted on

  • Prepared by

PATIENT ROOM:

  • PT. Room #

  • 1. Door Handle Cleaned?

  • 2. Glass Door Cleaned?

  • 3. Overbed Table Cleaned?

  • 4. Exam light Cleaned?

  • 5. Monitor Cleaned?

  • 6. Telephone Cleaned?

  • 7. Call light Cleaned?

  • 8. Chair in room Cleaned?

  • 9. Waste Can Cleaned?

  • 10. Floors Cleaned?

  • 11. Cubicle Curtain Cleaned & Functional?

  • 12. Room Organized?

PATIENT RESTROOM:

  • 1. Toilet Bowl Cleaned?

  • 2. Sink Cleaned?

  • 3. Supplies In Place?a

  • 4. Floors Cleaned?

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