Patient Room HRO

• Campus Location

• Conducted on

  Date

• Prepared by

• Employee Name:

• Room Location:

• Date Marked:

  Date

• Time Marked:

  Date

• Cleaning Type

  Daily

  Discharge

  N/A

• Date Inspected:

  Date

• Time Inspected:

  Date

Yes = Completely Removed / No = Appeared Untouched

• 1. Bathroom Light Switch

  Yes

  No

  N/A

• 2. Bed Pan Cleaner

  Yes

  No

  N/A

• 3. Bedside Table

  Yes

  No

  N/A

• 4. Call light/box (Including cord)

  Yes

  No

  N/A

• 5. Chairs in Room

  Yes

  No

  N/A

• 6. Room door knob/handle

  Yes

  No

  N/A

• 7. Side Rails

  Yes

  No

  N/A

• 8. Sink

  Yes

  No

  N/A

• 9. Telephone

  Yes

  No

  N/A

• 10. Bathroom door knob

  Yes

  No

  N/A

• 11. Bathroom hand hold

  Yes

  No

  N/A

• 12. Toilet handrail/handhold

  Yes

  No

  N/A

• 13. Toilet Seat

  Yes

  No

  N/A

• 14. Tray (over-bed) Table

  Yes

  No

  N/A