Audit

General Appearance

Building Exterior Clean

Entryway Clean and Neat

Lawn Cut and Presentable, Landscaping Not Overgrown

Parking Clean and Well Maintained

External Lighting Functional

Interior Areas Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

Additional failure areas? Use notes area to document.

Waiting Rooms

Furniture Clean

Windows Clean

Educational and Promotional Materials Available

Restrooms Clean and Stocked

Ceiling tiles stained

Patient bill of rights, FQHC, workplace violence, weapons free zone, and wait times signage posted

Additional failure areas? Use notes area to document.

Front Desk

Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

Ceiling Tiles Stained

PHI in View of Patients or Visitors

Phone Ringers Muted

Privacy practices brochure readily available

Additional failure areas? Use notes area to document.

Medical Exam Rooms. Click "Add Medical Exam Room" to add rooms. Place the actual room number in the room number field.

Medical Exam Rooms

Medical Exam Room

Room Number

Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

All surfaces clean and free of debris

Workplace violence and cell phone signage posted

Wall mounted scopes functional

Adequate supply of exam gloves in room

Cavicide disinfectant available in the room

Exam table clean and free of tears or damage

Walls free of scratches, gouges, and excessive hand prints

Sharps overfilled

Biohazard trash not overflowing or putrid

Excess supplies stored in room

Expired supplies stored in room

Waste basket overflowing

Sink functional, hot and cold, no leaks

Hand sanitizer, soap, paper towels filled

Ceiling Tiles Stained

Additional failure areas? Use notes area to document.

Nurses Station

Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

Food Present

AED present, tested, and supplies not expired

Ceiling Tiles Stained

PHI in View of Patients or Visitors

Phone Ringers Muted

Additional failure areas? Use notes area to document.

Medication Closet

Door locked and not propped open. Required staff members have access.

All medications labeled with expiration date

Expired medications on shelves

Narcotic log review. Does pad number match log? Any irregularities on log?

Additional failure areas? Use notes area to document.

Lab Area

CLIA waiver posted

Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

All surfaces clean and free of debris

Cavicide disinfectant available in the room

Biohazard items clearly separate from clean

Walls free of scratches, gouges, and excessive hand prints

Sharps overfilled

Biohazard trash not overflowing or putrid

Excess supplies stored in room

Expired supplies stored in room

Sink functional, hot and cold, no leaks

Waste basket overflowing

O2 tank available, stored properly, and above 500 psi left on guage

Hand sanitizer, soap, paper towels filled

Ceiling Tiles Stained

Vaccine Temperature Log Audit

All Equipment Functional

All equipment daily/weekly/monthly checks logged

Additional failure areas? Use notes area to document.

Dental

Is there dental in this office?

Dental Lab

Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

All surfaces clean and free of debris

O2 tank available, stored properly, and above 500 psi left on guage

Cavicide disinfectant available in the room

Walls free of scratches, gouges, and excessive hand prints

Sharps overfilled

Biohazard items clearly separate from clean

Biohazard trash not overflowing or putrid

Excess supplies stored in room

Expired supplies stored in room

Sink functional, hot and cold, no leaks

Eyewash Present and Functional

Waste basket overflowing

Hand sanitizer, soap, paper towels filled

Ceiling Tiles Stained

All Equipment Functional

All equipment checks logged. Autoclave cleaning, trap cleaning, eyewash testing

Dental assistant certificates and radiology licenses posted for a DA's present

Site radiology license current

Spore testing logged every Monday. (check back four weeks in the log)

Additional failure areas? Use notes area to document.

Dental Exam Rooms

Click "Add Dental Exam Room" to add rooms. Place the actual room number in the room number field.

Dental Exam Room

Exam Room Number

Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

All surfaces clean and free of debris

Workplace violence and cell phone signage posted

Cavicide disinfectant available in the room

Adequate supply of exam gloves in room

Exam chair clean, free of tears, and functional

All equipment functional and free of leaks

Walls free of scratches, gouges, and excessive hand prints

Sharps overfilled

Biohazard trash not overflowing or putrid

Excess supplies stored in room

Expired supplies stored in room

Waste basket overflowing

Sink functional, hot and cold, no leaks

Hand sanitizer, soap, paper towels filled

Ceiling Tiles Stained

Lead apron available, hung properly, not folded or creased

Additional failure areas? Use notes area to document.

X-Ray Development Area

Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

Ceiling Tiles Stained

Disinfectant available in room

Is pano X-ray apron available, hung properly, not folded or creased

Additional failure areas? Use notes area to document.

Fire, Life, and General Safety

Medical staff questioned on room and instrument disinfection

Dental staff questioned on room and instrument disinfection

All exit lights tested and functional

Items stored in hallways

Items stored within 18" of ceiling

Items stored within 36" of breaker panel

Extension cords in use (power strips ok)

Fire extinguishers inspected in last year

Space heaters in use

All secure area doors locked and not propped open

All staff members wearing ID Badges

Additional failure areas? Use notes area to document.

Staff Break Area

Generally Neat In Appearance, All Lights Functional, All Horizontal Surfaces Free of Dust, Floors Clean and Dry

Sink clean with no dishes present

Microwave clean

Trash overflowing

Refrigerator and freezer clean

Staff restrooms clean and stocked

Additional failure areas? Use notes area to document.

Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.