Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
Medication Refrigerator
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Sign on FRONT of refrigerator door "Medication only"
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Refrigerator is Clean
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Contains only medications
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Temperature is recorded daily
Nourishment Refrigerator
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Sign on front states "Patient Food Only"
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Patient food only: no partially eaten food
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Food is labeled, dated and covered
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Temperature is recorded daily
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Refrigerator is clean
Supply Storage area
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Supply area is clean and dust free
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Appropriate Storage (18" from ceiling and nothing under sink)
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Supply packaging intact
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No expired supplies
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Supply cart has a solid bottom
Exam rooms
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Exam Room
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Adequate hand washing supplies available
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No expired hand foam
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No expired supplies in exam room
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Exam room is clean and dust free
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Nothing is stored under sink
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Ceiling tiles without stains
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Exam table without tears
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Floor clean
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Sharps container no more than 2/3 full, is readily accessible, attached to fixed surface and locked
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Trash can with no trash overflowing
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CPR mask or ambu-bag available
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PPE available
Waste Storage area
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Doors to storage room are closed and locked at all times
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Lids kept on at all times
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Room is clean and dust free
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No stained ceiling tiles
Waiting Room
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Clean and dust free
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Tissue available
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Hand sanitizer available
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Ceiling tiles without stains
General
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Air vents clean
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Boxes off the floor
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No trash cans overflowing
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No signs of bugs on floor or in overhead lights
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Work area free of food and drink
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Staff know contact time of disinfectant in use
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Equipment clean and dust free (EKG, treadmill, procedure carts etc.)
Corrective/Preventive Action Plan
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A corrective/preventive action plan is indicated based on the audit results.
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Follow up audit date if corrective action required
Signature
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Auditor Comments
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Auditor signature
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Director/Manager signature
