Medication Refrigerator

Sign on FRONT of refrigerator door "Medication only"

Refrigerator is Clean

Contains only medications

Temperature is recorded daily

Nourishment Refrigerator

Sign on front states "Patient Food Only"

Patient food only: no partially eaten food

Food is labeled, dated and covered

Temperature is recorded daily

Refrigerator is clean

Supply Storage area

Supply area is clean and dust free

Appropriate Storage (18" from ceiling and nothing under sink)

Supply packaging intact

No expired supplies

Supply cart has a solid bottom

Exam rooms

Exam Room

Adequate hand washing supplies available

No expired hand foam

No expired supplies in exam room

Exam room is clean and dust free

Nothing is stored under sink

Ceiling tiles without stains

Exam table without tears

Floor clean

Sharps container no more than 2/3 full, is readily accessible, attached to fixed surface and locked

Trash can with no trash overflowing

CPR mask or ambu-bag available

PPE available

Waste Storage area

Doors to storage room are closed and locked at all times

Lids kept on at all times

Room is clean and dust free

No stained ceiling tiles

Waiting Room

Clean and dust free

Tissue available

Hand sanitizer available

Ceiling tiles without stains

General

Air vents clean

Boxes off the floor

No trash cans overflowing

No signs of bugs on floor or in overhead lights

Work area free of food and drink

Staff know contact time of disinfectant in use

Equipment clean and dust free (EKG, treadmill, procedure carts etc.)

Corrective/Preventive Action Plan

A corrective/preventive action plan is indicated based on the audit results.

Follow up audit date if corrective action required

Signature

Auditor Comments

Auditor signature
Director/Manager 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.