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?

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