There is no equipment / other objects in corridor for more than 30 minutes?

All objects that are in the corridor are on the same side?

Does the EVS staff know the "kill time" for the solution they are using? (Time surface must remain wet)

There were no soiled, wet, or damages surfaces? (Rodents)

No staff food in the patient refrigerator?

The inside of the refrigerator is clean?

Do all patient medication and nutrition refrigerators have 100% completed temperature logs?

There are no soiled or wet ceiling tiles?

Are all EVS closets neat and "uncluttered" with the door closed?

Are Utility room doors closed?

Is the floor free of door wedges?

Do all fire extinguishers have monthly checks?

For all months?

Are all linen carts covered?

If EVS staff is pouring chemicals, are they wearing eye protection?




Staff that are observed. Did they wash in / wash out?

Are there any employees with artificial nails or nails longer than 1/4 inch or chipped?

Observe that patients are being identified with 2 patient identifiers when a nurse administers a medication.

Locate an isolation patient and observe if it is being adhered too by staff, physicians and visitors as available?

Did staff know how to test the defibrillator?

Are all oxygen tanks in proper holders?

Were staff able to explain RACE and PASS?

Did the multidose vials have a "do not use beyond (date)"?

Were all staff wearing name badges?

Did staff identify themselves when they entered a patient room?


Medical record review

Medical Records Review:

Are all paper chart documents labeled with appropriate patient information?

Is each entry dated, timed, and signed? Including consents.

Is the care plan complete and updated?

If patient was medicated for pain, is reassessment documented?

Did patient receive appropriately ordered medication for the level of pain s/he described (mild, moderate, severe)?

If patient is in isolation, is there documentation that the patient/family has been educated?

Was a history and physical completed within 24 hours of admission?

If it was performed prior to admission and patient had surgery/invasive procedure, is the history and physical updated!

If patient is documented to be at risk for fall, see if patient has yellow bracelet and stars at the door?

Are home/current medications listed in chart?

Are there any "Do not use" abbreviations on handwritten documentation?


Staff interviews

Staff Interviews:

Was the staff able to explain the hand off process used at EMCM?

Was the staff able to describe the process for managing critical values?

Was the staff able to describe PI initiatives with which their unit has been involved?

Enter a description:

Does the staff know what a CODE RED is and what their role is?

Does the staff know what a CODE PINK is and what their role during the code?

Does the staff know where the nearest fire extinguisher is?

Pull station?

Does the staff know what the MSDS is?

How to locate and access the MSDS information?


Staff naarative

Staff Narrative:

What was working well today?

Are there any specific areas that need attention and why?

Are there any areas that should be recognized and what makes them notable?

Did you receive any negative feedback from patients, visitors, employees or physicians? If so, how do you plan to address and resolve the issues?

Is there anything we can do better?

Quarterly Focus

Was a specific task being performed? ( I.e. equipment cleaning, chemical disposal, etc)?


Did you identify anything that could affect the patient experience (I.e. wash in / wash out, staff fingernails, wearing. Name badges, clutter in hallways, etc.)?

Do you have any recommendations to morose the issues you identified?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.