Date and Time of Audit:


Auditor Name:

Personnel Interviewed:

Staff Names:

Miscellaneous Findings:

Other Noncompliant Findings?

Environment of Care
Oxygen Storage

Appropriate storage of oxygen tanks: never used tanks (as indicated by green
cap over oxygen nozzle) are stored separately from partially used and empty

Full Unused and Partially Used signs are posted on the appropriate racks


Point of care testing strips and control solutions are labeled with expiration date

Solutions and test strips used during HLD/sterile processes are within expiration

No expired supplies

No expired specimen containers or specimen collection supplies


Multi-dose vials not stored in patient care area

No expired medications

Medications secured in a locked cabinet or locked room


No drug samples

No products or educational material with vendor name on it


All patient information is stored properly. Computers, or patient equipment
displaying PHI, not in use are logged off

Equipment Storage

Assure the bottom shelf of storage carts has a solid bottom

Storage greater than 18 inches from sprinklers

IVF, syringes, needles are locked and secure, unless in visible area at all times

Equipment Logs

Thermometers in refrigerators and temperatures checked daily, if applicable

Crash cart is locked, lock number recorded/emergency equipment log maintained only current month available out on unit

Crash cart log completed for all days the area is open

Eye wash stations are operational and logs are completed weekly for each eyewash station

Fluid and Blanket Warmers

Blanket warmers have proper signage and are set not to exceed 130 degrees F (54.4 degrees C). No IV fluids are being warmed in blanket warmers.

Fluid warmers have proper signage and are set not to exceed 104 degrees F (40 degrees C).

Temperature logs are up to date with temperature documented daily

For fluid warmers, all IV fluids are dated and timed not to exceed 14 days in a warmer

Cleaning and Disinfection

Cleaning solutions labeled and do not exceed manufacturer expiration date

Medical equipment is clean

SDS and Instructions for Use (IFU) manual available in clinic

Eye wash in every room where chemicals are sprayed or high level disinfection or sterilization occurs

Patient care areas are free of visible dirt, dust, and stains

Staff speak to appropriate handling of used instruments as applicable to the device (pre-cleaning, rinsing, stored in open position, instruments kept moist prior to transport to CSD, e.g., sprayed with enzymatic)

Patient Care Environment

Patient Bill of Rights poster is present and current.

Hallways clear - no equipment stored in hallway

Medical equipment has appropriate clinical engineering services tag and not
expired (if applicable)

Fall Prevention: Floors not slippery. Adequate seating. Have ADA compliant restroom. Surfaces even for walkers and wheelchairs. Staff understand how to assist those appearing to be at risk for falling.

All red bag trash is covered

Emergency pull cords in exam rooms and patient bathrooms are no more than 6 inches from the floor without touching the floor

Emergency pull cords in exam rooms and patient bathrooms are functional

Electric panels and medical gas panels are free from obstructions

Medical equipment is plugged directly into wall outlet or plugged into a power strip that is permanently attached to the equipment assembly (e.g. a cart). Power strips are not plugged into other power strips (daisy chain).

Staff Interview

How to report a patient/visitor/staff event
Follow chain of command, notify provider as appropriate, enter events (e.g. falls, unexpected events) into event reporting system

* Preventing Infections information provided to patient
Know how your clinical area assures your patient receives this.
Posted in waiting area, sent via Smart Source, or in AVS.

What to do if a patient, visitor, or staff member has a possible stroke, heart attack, or any other medical emergency
call 5-4444 at any time (24/7)

Where to pull up disaster plan information

What the key Performance Indicators are
Ex. Hand hygiene, patient satisfaction, reduce readmissions, etc.

How critical action values (CAV) are handled

Frequency that BP cuffs, exam tables, and medical equipment are disinfected (minimum of once daily and when visibly soiled)

Secure storage of prescription pads including storage of controlled substance prescription pads in the Pyxis

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.