• Document No.

  • Client / Site

  • Conducted on

  • Prepared by

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


  • 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


  • Auditor Comments

  • Auditor signature

  • Director/Manager signature

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.