Clinical Unit Performed On
Coffee Station; solarium; hallway
Coffee station
Coffee area stocked; cup dispenser filled
Sink cleaned and polished
Counters wiped, machine dusted
Trash emptied, can cleaned
Floors need:
buffing
scrubbing
stripping/waxing
Solarium Linen room
Linen covered properly
Floors clean, free of dust bunnies
No linen, pillows, etc on top of carts without being bagged
Floors need:
buffing
scrubbing
stripping/waxing
Med room
Soiled utility Hallway
Room 320
Floor dust/dirt free corners/edges
Floor under furniture dust/dirt free
Walls dust/dirt free including corners
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Floors need:
buffing
scrubbing
stripping/waxing
Work orders needed:
Room 321
Floor dust/dirt free corners/edges
In Working Order
Work Order needed
Not Applicable
Floor under furniture dust/dirt free
In Working Order
Work Order needed
Not Applicable
Walls dust/dirt free including corners
In Working Order
Work Order needed
Not Applicable
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Floors need:
buffing
scrubbing
stripping/waxing
Work orders needed:
Room 322
Floor dust/dirt free corners/edges
In Working Order
Work Order needed
Not Applicable
Floor under furniture dust/dirt free
In Working Order
Work Order needed
Not Applicable
Walls dust/dirt free including corners
In Working Order
Work Order needed
Not Applicable
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Floors need:
buffing
scrubbing
stripping/waxing
Work orders needed:
Room 323
Floor dust/dirt free corners/edges
In Working Order
Work Order needed
Not Applicable
Floor under furniture dust/dirt free
In Working Order
Work Order needed
Not Applicable
Walls dust/dirt free including corners
In Working Order
Work Order needed
Not Applicable
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Floors need:
buffing
scrubbing
stripping/waxing
Work orders needed:
Room 324
Floor dust/dirt free corners/edges
In Working Order
Work Order needed
Not Applicable
Floor under furniture dust/dirt free
In Working Order
Work Order needed
Not Applicable
Walls dust/dirt free including corners
In Working Order
Work Order needed
Not Applicable
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Floors need:
buffing
scrubbing
stripping/waxing
Work orders needed:
Room 325
Floor dust/dirt free corners/edges
In Working Order
Work Order needed
Not Applicable
Floor under furniture dust/dirt free
In Working Order
Work Order needed
Not Applicable
Walls dust/dirt free including corners
In Working Order
Work Order needed
Not Applicable
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Floors need:
buffing
scrubbing
stripping/waxing
Work orders needed:
Room 326
Floor dust/dirt free corners/edges
In Working Order
Work Order needed
Not Applicable
Floor under furniture dust/dirt free
In Working Order
Work Order needed
Not Applicable
Walls dust/dirt free including corners
In Working Order
Work Order needed
Not Applicable
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Floors need:
buffing
scrubbing
stripping/waxing
Work orders needed:
Room 327
Floor dust/dirt free corners/edges
In Working Order
Work Order needed
Not Applicable
Floor under furniture dust/dirt free
In Working Order
Work Order needed
Not Applicable
Walls dust/dirt free including corners
In Working Order
Work Order needed
Not Applicable
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Floors need:
buffing
scrubbing
stripping/waxing
Work orders needed:
Engineering issues
Lighting is in good condition
In Working Order
Work Order needed
Not Applicable
Light Pull Chord in working condition
In Working Order
Work Order needed
Not Applicable
Plumbing in working condition
In Working Order
Work Order needed
Not Applicable
Ceiling tiles and tbar are clean with no stains, cracks, or missing
In Working Order
Work Order needed
Not Applicable
Paint is in good condition
In Working Order
Work Order needed
Not Applicable
Doors are in working condition including all hinges
In Working Order
Work Order needed
Not Applicable
Bathroom door in working order
In Working Order
Work Order needed
Not Applicable
Shower door in working order
In Working Order
Work Order needed
Not Applicable
Patient Room door in working order
In Working Order
Work Order needed
Not Applicable
All outlets in working order
In Working Order
Work Order needed
Not Applicable
Vents are in working order and are clean of debris and dust
In Working Order
Work Order needed
Not Applicable
Nurse Call working properly?
In Working Order
Work Order needed
Not Applicable
TV working properly in correlation to the Nurse Call System?
In Working Order
Work Order needed
Not Applicable
Are there any holes in the walls?
In Working Order
Work Order needed
Not Applicable
No Penetrations in the corridors or stairwell
In Working Order
Work Order needed
Not Applicable
All fire doors latch and close properly
In Working Order
Work Order needed
Not Applicable
All exit signs are properly working
In Working Order
Work Order needed
Not Applicable
All stairwell passage lights are working properly?
In Working Order
Work Order needed
Not Applicable
Are all means of egress free of obstruction both internal and external?
In Working Order
Work Order needed
Not Applicable
Is flooring in good condition?
In Working Order
Work Order needed
Not Applicable
Work orders needed:
Approval of these rounds are accepted by:
EVS Representative:
Sign
Clinical Unit Director/CSM
Sign
Engineering Representative:
Sign
link copied
Dauterive Hospital
Evs rounds - 3rd Rehab Snf Hall
Clinical Environmental rounds
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