Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Select date
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TO ENSURE THAT THE AMA AREA IS SAFE AND CHECKED EACH SHIFT, IT IS THE RESPONSIBILITY OF THE CHARGE NURSE TO HAVE THIS REPORT AT THE COMMENCEMENT OF THE SHIFT. THIS SHOULD BE DONE BY 1000HRS.
EACH ROOM IS TO BE CHECKED, AND A RECORD OF THE CHECK TO BE COMPLETED. ALL CONTRABAND IS TO BE REMOVED AND PHOTOGRAPHED USING THIS APPLICATION BY PRESSING NO FIRST, THEN MEDIA TO ACTIVATE CAMERA
Contraband include:
toiletries
cords, belts, shoe laces
aerosols
electrical equipment
LIGHTERS AND CIGARETTES
excessive clothing to be removed from area.
food is to be stored in the kitchenette area.
Plastic bags to be removed from area.
check for damage to walls, doors, beds, light fixtures,
check under beds for secreted items.
ALL HAZARDS ARE TO BE RECORDED AND REPORTED TO SHIFT LEADER.
Once complete, please email this report to jimmy.castro@monashhealth.org for auditing.
THANK YOU FOR PROMOTING A SAFER WORK ENVIRONMENT. -
AMA DINING AREA/KITCHENETTE
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AREA CLEAN AND TIDY? COMMENT IF NOT.
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ARE THE CHAIRS OR TABLE FREE FROM DAMAGE?
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LOUNGE/TV AREA
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AREA CLEAN AND TIDY? COMMENT IF NOT.
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ARE THE CHAIRS/COUCHES FREE FROM DAMAGE?
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BEDROOM 1
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ARE ALL BELONGINGS STORED AWAY? IF NOT, REMOVE ITEMS FOR PROPER STORAGE AND MAKE AS "NO".
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IS THE ROOM CLEAR OF ANY VISIBLE DAMAGE TO WALLS, DOORS, WINDOWS, BED, TABLE, LIGHT FIXTURES. IF NOT, COMMENT AND MARK AS "NO". REPORT TO SHIFT LEADER.
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BATHROOM
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IS THE BATHROOM CLEAR OF CONTRABAND. CLEAR HAZARDS AND MARK AS NO.
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IS THE ROOM CLEAR OF ANY VISIBLE DAMAGE TO WALLS, DOORS, LIGHT FIXTURES, SINK. IF NOT, COMMENT AND MARK AS "NO". NOTIFY SHIFT LEADER.
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ADMISSION ENTRY DOOR
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IS THE DOOR SECURE AND LOCKED?
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IS THE DOOR AND LOCK FREE FROM DAMAGE?
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BEDROOM 2
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ARE ALL BELONGINGS STORED AWAY? IF NOT, REMOVE ITEMS FOR PROPER STORAGE AND MAKE AS "NO".
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IS THE ROOM CLEAR OF ANY VISIBLE DAMAGE TO WALLS, DOORS, WINDOWS, BED, TABLE, LIGHT FIXTURES? IF NOT, COMMENT AND MARK AS "NO". NOTIFY SHIFT LEADER.
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BEDROOM 3
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ARE ALL BELONGINGS STORED AWAY? IF NOT, REMOVE ITEMS FOR PROPER STORAGE AND MAKE AS "NO".
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IS THE ROOM CLEAR OF ANY VISIBLE DAMAGE TO WALLS, DOORS, WINDOWS, BED, TABLE, LIGHT FIXTURES? IF NOT, COMMENT AND MARK AS "NO". REPORT TO SHIFT LEADER.
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SECRET GARDEN (REAR) DOOR
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IS THE DOOR SECURE AND LOCKED?
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IS THE DOOR AND LOCK FREE FROM DAMAGE? IF NOT, REPORT TO SHIFT LEADER.
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LAUNDRY AREA
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AREA CLEAN AND TIDY? COMMENT IF NOT.
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IS THE DOOR AND LOCK FREE FROM DAMAGE? IF NOT, REPORT TO SHIFT LEADER.
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SECLUSION AREA
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ARE THE DOORS KEPT SECURED AND LOCKED?
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IS THE AREA CLEAR OF ANY VISIBLE DAMAGE TO WALLS, DOORS, WINDOWS, BED, SHEETS? IF NOT, COMMENT AND MARK AS "NO".
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AREA CLEAN AND TIDY? COMMENT IF NOT.
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SECLUSION ROOM 1
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AREA CLEAN AND TIDY? COMMENT IF NOT.
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IS THE ROOM CLEAR OF ANY VISIBLE DAMAGE TO WALLS, DOORS, WINDOWS, BED, SHEETS? IF NOT, COMMENT AND MARK AS "NO". REPORT TO SHIFT LEADER.
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IS THE ROOM READY TO USE? IF NOT, ORGANISE FOR ROOM TO BE MADE. MARK AS YES WHEN PREPARED.
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SECLUSION ROOM 2
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AREA CLEAN AND TIDY? COMMENT IF NOT.
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IS THE ROOM CLEAR OF ANY VISIBLE DAMAGE TO WALLS, DOORS, WINDOWS, BED, SHEETS? IF NOT, COMMENT AND MARK AS "NO". REPORT TO SHIFT LEADER.
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IS THE ROOM READY TO USE? IF NOT, ORGANISE FOR ROOM TO BE MADE. MARK AS YES WHEN PREPARED.
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SECLUSION AREA COURTYARD
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ARE THE DOORS KEPT SECURED AND LOCKED?
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AREA CLEAN AND TIDY? COMMENT IF NOT. REMOVE HAZARDS.
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SIGN AMA CHECKLIST.
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IF ALL HAZARDS BEEN REMOVED FROM AREA, YOU CAN MARK AS SAFE. IF NOT, DISCUSS WITH SHIFT LEADER.
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CHECK COMPLETE.
EMAIL BY
1. PRESS EXPORT
2. PRESS SEND
3. ENTER jimmy.castro@monashhealth.org THEN SEND.
THANKYOU FOR MAKING AMA SAFER.
