Monitoring Terminal Cleaning

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date and time of audit:

  Date

• Unit:

• Room Number:

High Touch Room Surfaces

• Bed Rails/ controls

  Cleaned

  Not Cleaned

  Not Present in Room

• Tray Table

  Cleaned

  Not Cleaned

  Not Present in Room

• IV pole (grab area)

  Cleaned

  Not Cleaned

  Not Present in Room

• Call box/button

  Cleaned

  Not Cleaned

  Not Present in Room

• Telephone

  Cleaned

  Not Cleaned

  Not Present in Room

• Bedside Table Handle

  Cleaned

  Not Cleaned

  Not Present in Room

• Chair

  Cleaned

  Not Cleaned

  Not Present in Room

• Room sink

  Cleaned

  Not Cleaned

  Not Present in Room

• Room light switch

  Cleaned

  Not Cleaned

  Not Present in Room

• Room inner door knob

  Cleaned

  Not Cleaned

  Not Present in Room

• Bathroom inner door knob/plate

  Cleaned

  Not Cleaned

  Not Present in Room

• Bathroom light switch

  Cleaned

  Not Cleaned

  Not Present in Room

• Bathroom handrails by toilet

  Cleaned

  Not Cleaned

  Not Present in Room

• Bathroom Sink

  Cleaned

  Not Cleaned

  Not Present in Room

• Toilet seat

  Cleaned

  Not Cleaned

  Not Present in Room

• Toilet flush handle

  Cleaned

  Not Cleaned

  Not Present in Room

• Toilet bedpan cleaner

  Cleaned

  Not Cleaned

  Not Present in Room

Evaluate the following if present:

• IV pump control

  Cleaned

  Not Cleaned

  Not Present in Room

• Multi-module monitor controls

  Cleaned

  Not Cleaned

  Not Present in Room

• Multi-module monitor touch screen

  Cleaned

  Not Cleaned

  Not Present in Room

• Multi-module monitor cables

  Cleaned

  Not Cleaned

  Not Present in Room

• Ventilator control panel

  Cleaned

  Not Cleaned

  Not Present in Room

• Which method was used for monitoring?

  Select Direct observation Fluorescent gel Swab cultures ATP system Agar slide cultures

  • Direct observation
  • Fluorescent gel
  • Swab cultures
  • ATP system
  • Agar slide cultures

• Notes:

• Yes

  No

  N/A