PT. Room #

1. Head Wall Control Cleaned?

2. Door Handle Cleaned?

3. Glass Door Cleaned?

4. Bedside Table Cleaned?

5. Cart/Tray Cleaned

6. Exam light Cleaned?

7. Monitor Cleaned?

8. Telephone Cleaned?

9. Call light Cleaned?

10. Chair in room Cleaned?

11. Waste Can Cleaned?

12. Floors Cleaned?

13. Cubicle Curtain Cleaned & Functional?

14. Room Organized?


1. Toilet Bowl Cleaned?

2. Sink Cleaned?

3. Shower Cleaned?

4. Shower Curtain Cleaned?

5. Shower Curtain Functional ?

6. Supplies In Place?

7. Floors Cleaned?

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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.