Exam Room CLEANING

• Date

  Date

• Employee Name

• EID #

• Facility

  Broadway

  SMCF

  South University

• room location

• Prepared by

WASTE & RESTOCK DISPOSABLES

• soap

  Yes

  No

  N/A

• lotion

  Yes

  No

  N/A

• sharps - change when 2/3 full

  Yes

  No

  N/A

• paper towels

  Yes

  No

  N/A

• wastebaskets emptied, wiped and the liners replaced (2-3 left in bottom)

  Yes

  No

  N/A

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

GENERAL CLEANING PATHWAY

• high dusting - including lights & vents

  Yes

  No

  N/A

• doorknob, door frame, hinges

  Yes

  No

  N/A

• light switches

  Yes

  No

  N/A

• nurse call light & cord

  Yes

  No

  N/A

• chairs

  Yes

  No

  N/A

• desks, countertops & sides

  Yes

  No

  N/A

• drawer pulls/handles

  Yes

  No

  N/A

• sink/faucet/handles/vanity

  Yes

  No

  N/A

• mirrors

  Yes

  No

  N/A

• spot clean walls

  Yes

  No

  N/A

• wipe garbage can inside and out

  Yes

  No

  N/A

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

  N/A

RAG CHANGES

• rag changes sufficient

  Yes

  No

  N/A

FLOORS & SERVICE

• place clean liner in can with 2-3 extra in the bottom

  Yes

  No

  N/A

• dust mop floor with appropriate head

  Yes

  No

  N/A

• place wet floor sign

  Yes

  No

  N/A

• wet mop floor with microfiber mop head

  Yes

  No

  N/A

• vacuum carpet and spot clean as needed

  Yes

  No

  N/A

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

  N/A

ROOM COMPLETION

• look over room

  Yes

  No

  N/A

• complete work orders

  Yes

  No

  N/A

General Comments

• undefined