ICU - Environmental Quality Evaluation - (E.Q.E.) Revised*

• Division/Location

• Conducted on

  Date

• Prepared by

PATIENT ROOM:

• PT. Room #

• 1. Head Wall Control Cleaned?

  Yes

  No

  N/A

• 2. Door Handle Cleaned?

  Yes

  No

  N/A

• 3. Glass Door Cleaned?

  Yes

  No

  N/A

• 4. Bedside Table Cleaned?

  Yes

  No

  N/A

• 5. Cart/Tray Cleaned

  Yes

  No

  N/A

• 6. Exam light Cleaned?

  Yes

  No

  N/A

• 7. Monitor Cleaned?

  Yes

  No

  N/A

• 8. Telephone Cleaned?

  Yes

  No

  N/A

• 9. Call light Cleaned?

  Yes

  No

  N/A

• 10. Chair in room Cleaned?

  Yes

  No

  N/A

• 11. Waste Can Cleaned?

  Yes

  No

  N/A

• 12. Floors Cleaned?

  Yes

  No

  N/A

• 13. Cubicle Curtain Cleaned & Functional?

  Yes

  No

  N/A

• 14. Room Organized?

  Yes

  No

  N/A

PATIENT RESTROOM:

• 1. Toilet Bowl Cleaned?

  Yes

  No

  N/A

• 2. Sink Cleaned?

  Yes

  No

  N/A

• 3. Shower Cleaned?

  Yes

  No

  N/A

• 4. Shower Curtain Cleaned?

  Yes

  No

  N/A

• 5. Shower Curtain Functional ?

  Yes

  No

  N/A

• 6. Supplies In Place?

  Yes

  No

  N/A

• 7. Floors Cleaned?

  Yes

  No

  N/A

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