Title Page

  • Division/Location

  • Conducted on

  • Prepared by

PATIENT VISITATION:

  • Have you seen your housekeeper today?

  • How would you rate the cleanliness of your room?

  • Any Housekeeping issues or concerns?

PATIENT ROOM:

  • PT. Room #

  • 1. Overbed Table Cleaned?

  • 2. Night Stand Cleaned?

  • 3. Phone Cleaned?

  • 4. T.V Cleaned free of Dust?

  • 5. Picture Frame free of Dust?

  • 6. Overbed Light Cleaned free of Dust?

  • 7. Closet Cleaned?

  • 8. Walls Cleaned?

  • 9. Vents Cleaned free of Lint?

  • 10. Ceiling Cleaned?

  • 11. Door Cleaned?

  • 12. Door Handle Cleaned?

  • 13. Door Frame Cleaned?

  • 14. Waste Can Cleaned?

  • 15. Floors Cleaned?

  • 16. Cubicle Curtain Cleaned?

  • 17. Cubicle Curtain Functional?

  • 18. Room Organized?

PATIENT RESTROOM:

  • 1. Toilet Bowl Cleaned?

  • 2. Sink Cleaned?

  • 3. Shower Cleaned?

  • 4. Shower Curtain Cleaned?

  • 5. Shower Curtain Functional ?

  • 6. Supplies In Place?

  • 7. Floors Cleaned?

ANCILLARY AREA:

  • Ancillary Area:

  • Location:

  • 1. Cabinets Cleaned?

  • 2. Counters Cleaned?

  • 3. Sinks Cleaned?

  • 4. Walls Cleaned?

  • 5. Ceiling Cleaned?

  • 6. Ledges Cleaned?

  • 7. Vents Cleaned?

  • 8. Wastecans Cleaned & Freshly Lined?

  • 9. Supplies in Place?

  • 10. Floors Cleaned?

  • Corridor:

  • Location:

  • 1. Walls Cleaned?

  • 2. Ceiling Cleaned?

  • 3. Ledges Cleaned?

  • 4. Vents Cleaned?

  • 5. Floors Cleaned?

FLOORCARE:

  • Location:

  • 1. Baseboard Cleaned?

  • 2. Corners Cleaned?

  • 3. Edges Cleaned?

  • 4. Floors Finished / Carpet Clean?

ENVIRONMENTAL ROUNDS:

  • Personal Protective Equipment:

  • 1. Gloves?

  • 2. Eye Goggles?<br>

  • 3. Staff performing hand hygiene?

  • Chemical:

  • 1. Disinfection wipe container lids closed and labeled correctly?

  • 2. Chemical Dispensing unit in working condition?

  • 3. Disinfectant Wipe/bottle properly Dated?

  • Hopper Closet:

  • 1. Closet cleaned & organized?

  • 2. Eye Wash Station Clean & Checked?

  • 3. Work Charts Available?

  • 4. Housekeeping Cart Clean & Orderly?

  • Elevator:

  • Location:

  • 1. Elevator Tracks / Door Clean?

  • Stairwell:

  • Location

  • 1. Stairwell Clean free of Dust/Litter?a

  • 2. Stairwell Ledges / Handrails Clean?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.