• Audit Date

  • Clinical Area

  • Auditor

I Physical Environment

Physical Environment

  • No food/drinks in preparation work areas, specimen areas or WOWs

  • No multi serving food items in patient care/preparation areas

  • No personal/food items 12" near Hand Hygiene sink

  • No patient care supplies/equipment 12" near Hand Hygiene sink

  • Soap dispensers filled, not expired, and functioning properly

  • Alcohol hand rinse dispensers available, filled, not expired and functioning properly

  • Paper towel dispensers filled and functioning

  • No high dust and area dust free

  • Floors are clean

  • Surfaces and furnishings are clean

  • Bathrooms are clean

  • No missing or stained ceiling tiles

  • Area under sink is free from stored items

  • Computer keyboards/WOWs are clean without dust

  • Employee refrigerator free of unlabeled and expired food

  • Breastmilk refrigerator clean and free of unlabeled or expired milk

  • Other:

III Standard and Transmission Base Precautions

Standard Precautions and Transmissions Based Precautions

  • Current precautions signage available on unit

  • Appropriate PPE available on unit

  • Sharps containers secured & not overfilled

  • Other:

IV Equipment and Supplies

Equipment and Supplies

  • Storage so supplies dust free, 6" off floor, on solid bottom & 18" from ceiling

  • No expired supplies noted

  • No cardboard shipping boxes in supply storage

  • No dirty items in clean supply/designated area

  • No clean supplies in dirty utility/designated area

  • Equipment is clean

  • Equipment with biomedical or engineering tags are clean

  • Clean linen is covered and properly stored

  • Dirty linen is bagged in blue bag and covered

  • Other:

V Department Specific

Department Specific

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.