Title Page

  • Site conducted
  • Conducted on

  • Conducted by

  • Prepared by


  • Clean equipment placed in clean storage area or designated areas (labeled)

  • Proper wipes available to clean glucometer or urine dipstick machine (purple top)

  • Isolation cart stocked and clean

  • Code cart properly stored and log updated

  • Unopened electrode package on defibulator

  • Wheelchairs & other patient equipment clean

  • Eyewash stations clean (no calcification) & Logs up-to-date

Staff Area

  • Food & drink in appropriate areas

  • General cleanliness of nursing stations

Patient Nourishment Area

  • All patient food is labeled w/name & date (nothing older than 3 days)

  • No expired items in fridge

  • Fridge temp checked and logged daily

  • No staff food in patient fridge

  • General cleanliness of patient fridge

  • Ice machine is clean

  • General cleanliness of nourishment room

Clean Utility Room

  • All linens covered

  • No storage on floor

  • No dirty items stored

  • All storage 18in from sprinkler heads

  • No external/shipping boxes

Dirty Utility Room

  • Doors kept closed / not propped open

  • No clean items/equipment/patient items stored here

  • Room is clutterfree

  • Red biohazard containers are covered and not overflowing

Med Room/Area

  • Clean and meds secured

  • Fridge clean and temps checked and logged daily

  • No expired vials/meds or med supplies in use

  • Expiration date noted on packaging


  • No medications, IVs, or syringes left unsecured or unattended

  • No tape/label adhesive on floor or anywhere else

  • No shipping/external or corrugated boxes

  • No dust/dirt noted (high dusting done)

  • Floors/Walls clean, no dust, trash noted

  • Bedside curtains are clean, free of stains <br> (changed per schedule & when visibly contaminated)

Patient Rooms

  • No patient supplies found on window sills

  • No syringes/meds left unattended

  • No reuseable gait belts found in rooms

I.P. General

  • No Items are kept in the original shipping boxes, especially in the clinical areas

  • Clean supply rooms & Dirty utility rooms do not have doors propped open


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.