OR Room - Environmental Quality Evaluation (E.Q.E.) Revised*

• Division/Location

• Conducted on

  Date

• Prepared by

OR ROOM:

• OR Room #

• 1. Operating table clean?

  Yes

  No

  N/A

• 2. Surgical lights clean?

  Yes

  No

  N/A

• 3. Phone clean?

  Yes

  No

  N/A

• 4. Door / handle clean?

  Yes

  No

  N/A

• 5. Light switch clean?

  Yes

  No

  N/A

• 6. Omnicell clean?

  Yes

  No

  N/A

• 7. Walls clean?

  Yes

  No

  N/A

• 8. Ceiling clean?

  Yes

  No

  N/A

• 9. Waste can clean?

  Yes

  No

  N/A

• 10. Ledges free of dust?

  Yes

  No

  N/A

• 11. Vents free of dust?

  Yes

  No

  N/A

• 12. Flat surface tables clean?

  Yes

  No

  N/A

• 13. Mayo stand clean?

  Yes

  No

  N/A

• 14. Ring stand clean?

  Yes

  No

  N/A

• 15. IV Pole clean? (Without mechanical device)

  Yes

  No

  N/A

• 16. Step stools clean?

  Yes

  No

  N/A

• 17. Chairs clean?

  Yes

  No

  N/A

• 18. Floors clean?

  Yes

  No

  N/A

SUB-STERILE ROOM:

• 1. Counters Cleaned?

  Yes

  No

  N/A

• 2. Sink Cleaned?

  Yes

  No

  N/A

• 3. Walls Cleaned?

  Yes

  No

  N/A

• 4. Doors Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Supplies In Place?

  Yes

  No

  N/A

• 7. Floors Cleaned?

  Yes

  No

  N/A

• Signature:

  Sign