Title Page

  • Division/Location

  • Conducted on

  • Prepared by

PATIENT ROOMS

Patient Room 1

  • 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

  • 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?

Patient Room 2

  • 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 2

  • 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?

WAITING ROOM / Public Restroom

  • Location:

  • Overall condition of the waiting room cleaned?

  • Location:

  • Overall condition of the public restroom cleaned?

ANCILLARY AREA

Ancillary Area 1

  • Location:

  • 1. Cabinets Cleaned?

  • 2. Counters Cleaned?

  • 3. Sinks Cleaned?

  • 4. Walls Cleaned?

  • 5. Ceiling Cleaned?

  • 6. Ledges Cleaned?

  • 7. Vents Cleaned?

  • 8. Wastecans Cleaned & Freshly Lined?

  • 9. Supplies in Place?

  • 10. Floors Cleaned?

Ancillary Area 2

  • Location:

  • 1. Cabinets Cleaned?

  • 2. Counters Cleaned?

  • 3. Sinks Cleaned?

  • 4. Walls Cleaned?

  • 5. Ceiling Cleaned?

  • 6. Ledges Cleaned?

  • 7. Vents Cleaned?

  • 8. Wastecans Cleaned & Freshly Lined?

  • 9. Supplies in Place?

  • 10. Floors Cleaned?

FLOORCARE

Floorcare 1

  • Location:

  • 1. Baseboard Cleaned?

  • 2. Corners Cleaned?

  • 3. Edges Cleaned?

  • 4. Floors Finished / Carpet Clean?

Floorcare 2

  • Location:

  • 1. Baseboard Cleaned?

  • 2. Corners Cleaned?

  • 3. Edges Cleaned?

  • 4. Floors Finished / Carpet Clean?

ENVIRONMENTAL ROUNDS

Personal Protective Equipment

  • 1. Gloves?

  • 2. Eye Goggles?<br>

Chemical

  • 1. Disinfection wipe container lids closed and labeled correctly?

  • 2. Chemical Dispensing unit in working condition?

  • 3. Disinfectant Wipe/bottle properly Dated?

Hopper Closet

  • 1. Closet cleaned & organized?

  • 2. Eye Wash Station Clean & Checked?

  • 3. Work Charts Available?

  • 4. Housekeeping Cart Clean & Orderly?

Stairwell/Elevator

  • Location:

  • 1. Elevator Tracks / Door Clean?

  • Location

  • 2. Stairwell Clean free of Dust/Litter?

  • 3. Stairwell Ledges / Handrails Clean?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.