Information

  • Conducted on

  • Prepared by

  • Location

Patient Room

  • Room Number:

  • Is patient room occupied?

  • Ceiling tiles free from staining?

  • Add media

  • ABHR available/working

  • Add media

  • Soap, water and paper towel available

  • Add media

  • Sharps container < 3/4 full

  • No supplies stored under sink

  • Soiled linen in bag; not overfilled, hamper covered

  • Medication storage area clean

  • Refrigerator labeled to identify the approved use

  • Items within according to label

Isolation Rooms(s)

  • Correct sign in place (right sign, right reason)<br>Enter room numbers and isolation type in field below.

  • Add media

  • Supplies and PPE available

  • Add media

  • Staff compliant with policy

  • Add media

  • Airborne Precautions: Door closed

  • Airborne Precautions: Passes tissue test

  • Airborne Precautions: Inquire with Charge Nurse re:RNs on unit who are fit tested. List names of employees below.

Unit

Standard precautions

Clean Utility

Soiled Utility

EVS Closet/Cart

Public Use Restroom

ICRA

  • ICRA posted

  • Add media

  • ICRA posted within date range<br><br>

  • Add media

  • ICRA being followed

  • Add media

Waiting Area/Entry

  • Are appropriate supplies for respiratory hygiene available and posted instructions in place?

  • Add media

Patient Room

  • Enter room number in field below

  • Is the room occupied?

  • Ceiling tiles free from staining

  • ABHR available/working

  • Soap, water and paper towels available

  • Sharps container is less than 3/4 full

  • No supplies stored under sink

  • Soiled linen in bag; not overfilled,mhamper covered

  • Medication storage area clean

  • Refrigerator labeled to identify the approved use

  • Items within refrigerator according to label

Isolation Room

Unit

Standard precautions

clean Utility

Soiled Utility

EVS Closet/Cart

  • Clean in appearance

  • Free from safety concerns

  • Container labeled

  • Appropriate PPE available

  • Cart organized

Public Use Restroom

  • All surfaces appear clean

  • Add media

  • Hand-washing supplies available

  • Add media

  • Free from trash/debris

  • Add media

ICRA

  • ICRA posted

  • Add media

  • ICRA within date range

  • Add media

  • ICRA being followed

  • Add media

Waiting Area/Entry

  • If appropriate, supplies for respiratory hygiene available and posted instructions in place

  • Add media

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.