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

• Conducted on:

  Date

• Division/Location:

• Division Director:

• Division Manager:

• Prepared by EVS Management:

• Overall Summary:

PATIENT ROOM:

• PT. Room #

• 1. Overbed Table Cleaned?

  Yes

  No

  N/A

• 2. Night Stand Cleaned?

  Yes

  No

  N/A

• 3. Phone Cleaned?

  Yes

  No

  N/A

• 4. T.V Cleaned free of Dust?

  Yes

  No

  N/A

• 5. Picture Frame Clean & free of Dust?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 7. Closet Cleaned?

  Yes

  No

  N/A

• 8. Walls Cleaned?

  Yes

  No

  N/A

• 9. Vents Cleaned free of dust?

  Yes

  No

  N/A

• 10. Ceiling Cleaned?

  Yes

  No

  N/A

• 11. Door Cleaned?

  Yes

  No

  N/A

• 12. Door Handle Cleaned?

  Yes

  No

  N/A

• 13. Door Frame Cleaned?

  Yes

  No

  N/A

• 14. Waste Can Cleaned?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• a. Is appearance of the floors meet satisfactory condition?

  Yes

  No

• 16. Cubicle Curtain Cleaned & Fully Functional?

  Yes

  No

  N/A

• 17. Room/Furniture Organized?

  Yes

  No

  N/A

PATIENT RESTROOM:

• 1. Toilet Bowl Cleaned?

  Yes

  No

  N/A

• 2. Sink Cleaned?

  Yes

  No

  N/A

• 3. Shower Cleaned?

  Yes

  No

  N/A

• 4. Shower Curtain Cleaned & Fully Functional?

  Yes

  No

  N/A

• 5. Supply dispensers cleaned?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Signature By:

  Sign