Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

PSU Audit

    CDC Environmental Checklist for Monitoring Terminal Cleaning
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  • Location

  • Monitoring Method Used:

  • Bed rails/controls

  • Tray table

  • IV pole (grab area)

  • Call box/button

  • Telephone

  • Bedside table handle

  • Chair

  • Room sink

  • Room light switch

  • Room inner door knob

  • Bathroom inner door knob/plate

  • Bathroom light switch

  • Bathroom handrails by toilet

  • Bathroom sink

  • Toilet seat

  • Toilet flush handle

  • IV pump control

  • Multi-module monitor controls

  • Multi-module monitor touch screen

  • Multi-module monitor cables

  • Is this section free of additional findings?

  • Please describe other findings:

PreOp & PACU

    Modified CDC Environmental Checklist for Monitoring Terminal Cleaning
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  • Location

  • Monitoring Method Used:

  • Bed rails/controls

  • Tray table

  • IV pole (grab area)

  • Call box/button

  • Telephone

  • Bedside table handle

  • Chair

  • Room sink

  • Room light switch

  • Room inner door knob

  • Bathroom inner door knob/plate

  • Bathroom light switch

  • Bathroom handrails by toilet

  • Bathroom sink

  • Toilet seat

  • Toilet flush handle

  • IV pump control

  • Multi-module monitor controls

  • Multi-module monitor touch screen

  • Multi-module monitor cables

  • Is this section free of additional findings?

  • Please describe other findings:

OR Audit

    Decon - Direct Observations
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  • Perform hand hygiene

  • Don personal protective equipment

  • Collect linen

  • Remove large debris from floor

  • Remove trash and linen

  • Clean and disinfect: Anesthesia cart, including the top and drawer handle

  • Clean and disinfect: Anesthesia equipment (IV poles and pumps)

  • Clean and disinfect: Anesthesia machine

  • Clean and disinfect: Patient monitors, including cables

  • Clean and disinfect: OR beds

  • Clean and disinfect: Reusable table straps

  • Clean and disinfect: Bed attachments

  • Clean and disinfect: Positioning devices

  • Clean and disinfect: Patient transfer devices

  • Clean and disinfect: Overhead procedure lights

  • Clean and disinfect: Tables

  • Clean and disinfect: Mayo stands

  • Clean and disinfect: Mobile and fixed equipment (e.g., suction regulators, medical gas regulators, imaging monitors, radiology equipment, electrosurgical units, microscopes, robots, lasers)

  • Clean floors

  • Spot clean walls if visibly soiled

  • Remove PPE

  • Perform hand hygiene

  • Is this section free of additional findings?

  • Please describe other findings:

  • Audit 14 - Terminal Clean
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  • Operating Room (Procedure Room 1 = 8)

  • Monitoring Method Used:

  • White light switch

  • Circulator desk

  • Mouse

  • Telephone

  • Surgical table - upper corner

  • Automated dispensing cabinets keyboard (arrows)

  • Anesthesiologist chair - left corner seat

  • Anesthesiologist medication pole (grab area)

  • Backtable

  • Operating room light handle

  • Inner door knob - outside

  • Inner door knob - inside

  • Pseudo room door knob - inside OR

  • Floor - upper corner

  • Is this section free of additional findings?

  • Please describe other findings:

  • Audit 20 - Terminal Clean
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  • Operating Room (Procedure Room 1 = 8)

  • Monitoring Method Used:

  • All floors – wet vacuum or a single-use mop

  • Anesthesia cart

  • Anesthesia equipment

  • Anesthesia machines

  • Patient monitors, including cables

  • OR beds

  • Reusable table straps

  • OR bed attachments

  • Positioning devices

  • Patient transfer devices

  • Overhead procedure lights

  • Tables and Mayo stands

  • Mobile and fixed equipment

  • Storage cabinets or supply carts

  • Light switches

  • Push plates

  • Telephone handle

  • Computer accessories

  • Chairs, stools, and step stools

  • Trash and linen receptacles

  • Is this section free of additional findings?

  • Please describe other findings:

  • Surgical Scrub Stations
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  • Location

  • Left faucet spout

  • Right faucet spout

  • Left backsplash

  • Right backsplash

  • Left rim

  • Right rim

  • Left knee panel

  • Right knee panel

  • Pseudo room door knob plate - outside OR

  • Is this section free of additional findings?

  • Please describe other findings:

Completion

  • Additional Comments

  • Surveyor's Name and Signature

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