Audit

PATIENT ROOM:

PT. Room #

1. Overbed Table Cleaned?

Notes from question # (1)

Completion date:

2. Night Stand Cleaned?

Notes from question # (2)

Completion date:

3. Phone Cleaned?

Notes from question # (3)

Completion date:

4. T.V Cleaned free of Dust?

Notes from question # (4)

Completion date:

5. Picture Frame Clean & free of Dust?

Notes from question # (5)

Completion date:

6. Overbed Light Cleaned free of Dust? (Discharge Only)

Notes from question # (6)

Completion date:

7. Closet Cleaned?

Notes from question # (7)

Completion date:

8. Walls Cleaned?

Notes from question # (8)
Completion date:

9. Vents Cleaned free of dust?

Notes from question # (9)

Completion date:

10. Ceiling Cleaned?

Notes from question # (10)
Completion date:

11. Door Cleaned?

Notes from question # (11)

Completion date:

12. Door Handle Cleaned?

Notes from question # (12)

Completion date:

13. Door Frame Cleaned?

Notes from question # (13)

Completion date:

14. Waste Can Cleaned?

Notes from question # (14)

Completion date:

15. Is Floors being mopped according to standard cleaning procedure?

Notes from question # (15)

Completion date:

a. Is appearance of the floors meet satisfactory condition?

Notes from question # (15)
Completion date:

16. Cubicle Curtain Cleaned & Fully Functional?

Notes from question # (16)
Completion date:

17. Room/Furniture Organized?

Notes from question # (17)
Completion date:
PATIENT RESTROOM:

1. Toilet Bowl Cleaned?

Notes from question # (1)

Completion date:

2. Sink Cleaned?

Notes from question # (2)

Completion date:

3. Shower Cleaned?

Notes from question # (3)

Completion date:

4. Shower Curtain Cleaned & Fully Functional?

Notes from question # (4)
Completion date:

5. Supply dispensers cleaned?

Notes from question # (5)
Completion date:

6. Is Floors being mopped according to standard cleaning procedure?

Notes from question # (6)
Completion date:
ANCILLARY AREA:
Ancillary Area 1:
Location:

1. Outside Cabinets Cleaned?

Notes from question # (1)

Completion date:

2. Counters Cleaned?

Notes from question # (2)

Completion date:

3. Sinks Cleaned?

Notes from question # (3)

Completion date:

4. Walls Cleaned?

Notes from question # (4)
Completion date:

5. Ceiling Cleaned?

Notes from question # (5)
Completion date:

6. Ledges Cleaned?

Notes from question # (6)

Completion date:

7. Vents Cleaned?

Notes from question # (7)

Completion date:

8. Wastecans Cleaned & Freshly Lined?

Notes from question # (8)

Completion date:

9. Supply dispensers cleaned?

Notes from question # (9)
Completion date:

10. Is Floors being mopped according to standard cleaning procedure?

Notes from question # (15)

Completion date:

a. Is appearance of the floors meet satisfactory condition?

Notes from question # (16)
Completion date:
Ancillary Area 2:
Location:

1. Outside Cabinets Cleaned?

Notes from question # (1)

Completion date:

2. Counters Cleaned?

Notes from question # (2)

Completion date:

3. Sinks Cleaned?

Notes from question # (3)

Completion date:

4. Walls Cleaned?

Notes from question # (4)
Completion date:

5. Ceiling Cleaned?

Notes from question # (5)
Completion date:

6. Ledges Cleaned?

Notes from question # (6)

Completion date:

7. Vents Cleaned?

Notes from question # (7)

Completion date:

8. Wastecans Cleaned & Freshly Lined?

Notes from question # (8)

Completion date:

9. Supply dispensers cleaned?

Notes from question # (9)
Completion date:

10. Is Floors being mopped according to standard cleaning procedure?

Notes from question # (15)

Completion date:

a. Is appearance of the floors meet satisfactory condition?

Notes from question # (16)
Completion date:
Corridor:

1. Walls Cleaned?

Notes from question # (1)
Completion date:

2. Ceiling Cleaned?

Notes from question # (2)
Completion date:

3. Ledges Cleaned?

Notes from question # (3)
Completion date:

4. Vents Cleaned?

Notes from question # (4)

Completion date:

5. Floors Cleaned?

Notes from question # (5)
Completion date:
EVS COMPLIANCE:

1. Disinfection wipe container lids closed and labeled correctly? Chemical Dispensing unit in working condition?

Notes from question # (1)
Completion date:

2. Eye Wash sheets properly dated? (Unblocked)

Notes from question # (2)
Completion date:

3. Hopper rooms clean and in order? (No unnecessary items)

Notes from question # (3)
Completion date:

4. Hopper Room locked when not in use?

Notes from question # (4)

Completion date:

5. Housekeeping carts clean and free of unnecessary item?

Notes from question # (5)
Completion date:

6. Cart Locked and put away when not in use?

Notes from question # (6)
Completion date:

7 Equipment clean? (Vacuums, buffers & carts)

Notes from question # (7)

Completion date:

8. Staff have knowledge of R.A.C.E. (Rescue Alarm Contain Extinguish) and P.A.S.S. (Pull Aim Squeeze Sweep.)?

Notes from question # (8)
Completion date:

9. Staff have knowledge of Dwell time for Disinfectant? (Name of Disinfectant)

Notes from question # (9)
Completion date:

10. Performex?

Notes from question # (10)
Completion date:

11. Clorox Hydrogen Peroxide?

Notes from question # (11)
Completion date:

12. Does staff have knowledge of SDS? What is SDS? (Safety Data Sheets) Where is the SDS information located?

Notes from question # (12)
Completion date:

13. P.P.E. Available? (Gloves, Goggles is there evidence of use?) Hand Hygiene Being Performed? (Observation of Evidence)

Notes from question # (13)
Completion date:

14. Staff have knowledge of location of Fire Pull Stations?

Notes from question # (14)

Completion date:

15. Green Trash & Red Bio Hazard carts cleaned & lined? (McClure Carts)

Notes from question # (15)
Completion date:
Signature By:
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.