ED - Environmental Quality Evaluation - (E.Q.E.) Revised *

• Division/Location

• Conducted on

  Date

• Prepared by

PATIENT ROOM:

• PT. Room #

• 1. Door Handle Cleaned?

  Yes

  No

  N/A

• 2. Glass Door Cleaned?

  Yes

  No

  N/A

• 3. Overbed Table Cleaned?

  Yes

  No

  N/A

• 4. Exam light Cleaned?

  Yes

  No

  N/A

• 5. Monitor Cleaned?

  Yes

  No

  N/A

• 6. Telephone Cleaned?

  Yes

  No

  N/A

• 7. Call light Cleaned?

  Yes

  No

  N/A

• 8. Chair in room Cleaned?

  Yes

  No

  N/A

• 9. Waste Can Cleaned?

  Yes

  No

  N/A

• 10. Floors Cleaned?

  Yes

  No

  N/A

• 11. Cubicle Curtain Cleaned & Functional?

  Yes

  No

  N/A

• 12. Room Organized?

  Yes

  No

  N/A

PATIENT RESTROOM:

• 1. Toilet Bowl Cleaned?

  Yes

  No

  N/A

• 2. Sink Cleaned?

  Yes

  No

  N/A

• 3. Supplies In Place?a

  Yes

  No

  N/A

• 4. Floors Cleaned?

  Yes

  No

  N/A

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