Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
PSU Audit
- CDC Environmental Checklist for Monitoring Terminal Cleaning
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Location
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Monitoring Method Used:
- Direct observation
- Visual
- Fluorescent gel
- Visual
- Swab cultures
- ATP system
- Agar slide cultures
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Bed rails/controls
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Tray table
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IV pole (grab area)
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Call box/button
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Telephone
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Bedside table handle
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Chair
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Room sink
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Room light switch
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Room inner door knob
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Bathroom inner door knob/plate
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Bathroom light switch
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Bathroom handrails by toilet
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Bathroom sink
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Toilet seat
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Toilet flush handle
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IV pump control
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Multi-module monitor controls
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Multi-module monitor touch screen
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Multi-module monitor cables
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Is this section free of additional findings?
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Please describe other findings:
PreOp & PACU
- Modified CDC Environmental Checklist for Monitoring Terminal Cleaning
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Would you like to complete this section?
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Location
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Monitoring Method Used:
- Direct observation
- Visual
- Fluorescent gel
- Visual
- Swab cultures
- ATP system
- Agar slide cultures
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Bed rails/controls
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Tray table
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IV pole (grab area)
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Call box/button
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Telephone
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Bedside table handle
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Chair
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Room sink
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Room light switch
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Room inner door knob
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Bathroom inner door knob/plate
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Bathroom light switch
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Bathroom handrails by toilet
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Bathroom sink
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Toilet seat
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Toilet flush handle
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IV pump control
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Multi-module monitor controls
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Multi-module monitor touch screen
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Multi-module monitor cables
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Is this section free of additional findings?
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Please describe other findings:
OR Audit
- Decon - Direct Observations
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Perform hand hygiene
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Don personal protective equipment
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Collect linen
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Remove large debris from floor
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Remove trash and linen
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Clean and disinfect: Anesthesia cart, including the top and drawer handle
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Clean and disinfect: Anesthesia equipment (IV poles and pumps)
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Clean and disinfect: Anesthesia machine
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Clean and disinfect: Patient monitors, including cables
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Clean and disinfect: OR beds
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Clean and disinfect: Reusable table straps
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Clean and disinfect: Bed attachments
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Clean and disinfect: Positioning devices
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Clean and disinfect: Patient transfer devices
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Clean and disinfect: Overhead procedure lights
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Clean and disinfect: Tables
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Clean and disinfect: Mayo stands
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Clean and disinfect: Mobile and fixed equipment (e.g., suction regulators, medical gas regulators, imaging monitors, radiology equipment, electrosurgical units, microscopes, robots, lasers)
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Clean floors
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Spot clean walls if visibly soiled
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Remove PPE
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Perform hand hygiene
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Is this section free of additional findings?
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Please describe other findings:
Audit 14 - Terminal Clean
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Operating Room (Procedure Room 1 = 8)
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Monitoring Method Used:
- Direct observation
- Visual
- Fluorescent gel
- Visual
- Swab cultures
- ATP system
- Agar slide cultures
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White light switch
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Circulator desk
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Mouse
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Telephone
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Surgical table - upper corner
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Automated dispensing cabinets keyboard (arrows)
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Anesthesiologist chair - left corner seat
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Anesthesiologist medication pole (grab area)
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Backtable
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Operating room light handle
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Inner door knob - outside
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Inner door knob - inside
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Pseudo room door knob - inside OR
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Floor - upper corner
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Is this section free of additional findings?
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Please describe other findings:
Audit 20 - Terminal Clean
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Operating Room (Procedure Room 1 = 8)
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Monitoring Method Used:
- Direct observation
- Visual
- Fluorescent gel
- Visual
- Swab cultures
- ATP system
- Agar slide cultures
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All floors – wet vacuum or a single-use mop
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Anesthesia cart
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Anesthesia equipment
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Anesthesia machines
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Patient monitors, including cables
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OR beds
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Reusable table straps
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OR bed attachments
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Positioning devices
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Patient transfer devices
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Overhead procedure lights
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Tables and Mayo stands
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Mobile and fixed equipment
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Storage cabinets or supply carts
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Light switches
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Push plates
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Telephone handle
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Computer accessories
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Chairs, stools, and step stools
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Trash and linen receptacles
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Surgical Scrub Stations
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Location
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Left faucet spout
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Right faucet spout
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Left backsplash
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Right backsplash
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Left rim
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Right rim
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Left knee panel
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Right knee panel
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Pseudo room door knob plate - outside OR
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Is this section free of additional findings?
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Please describe other findings:
Completion
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Additional Comments
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Surveyor's Name and Signature