• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Items in front of outlets (Monthly)

  • Items directly on floors (Monthly)

  • General appearance of area. (Monthly)

  • Bathrooms - clean to sight and touch, free o odors. (Monthly)

  • Window, partition curtain and drapes are clean to sight and touch, free off odors. (Monthly)

  • Walls, ceilings and vents are clean to sight and touch, are in good repair. (Monthly)

  • Window and screens are clean o sight and touch and in good repair. (Monthly)

  • Spills. (Monthly)

  • Walkways/Hallways clear. (Monthly)

  • Exit doors not blocked. (Monthly)

  • Linens (clean/dirty) are covered and kept separately (Monthly)


  • No stapled cords on surfaces (Quarterly)

  • No hanging cords on nails (Quarterly)

  • Exposed cords on walkways (Quarterly)

  • Cords not used for permanent wiring (Quarterly)

  • Sinks and faucets and re from leaks or clogs

  • Outlet and switch plate covers in good repair (Quarterly)

  • Check space heaters (if in use) for condition, on while unattended, proximity to combustibles material (Monthly)

  • Hot water temperatures checked (110-120 degrees F) (Monthly)

  • Eye wash stations are being inspected weekly (Monthly)


  • Free of spurs (Qurterly)

  • Splinters (Quarterly)

  • Protruding nails (Quarterly)

  • Carpeting is clean, odor free and not frayed, worn, torn or buckled (Monthly)

  • Tripping hazards (Quarterly)


  • Drug cabinet locked (Montthly)

  • Anesthesia area and medication secured (Monthly)

  • CT contrast secured (Monthly)

  • Visitors and patients are escorted through secure areas (Monthly)

  • Individuals not recognized are challenged for ID (Monthly)

  • Staff visibly at all times (Monthly)


  • Fire extinguisher inspection tags are current (Monthly)

  • Exit doors are clear of obstructions

  • Fire/Smoke doors properly close and latch, and are unobstructed (Monthly)

  • Emergency safety features (alarm pull stations, extinguishers, oxygen zone valves are unobstructed (Monthly)

  • Exit and emergency signs are operational.

  • Unsafe or combustible storage stored properly (Monthly)


  • Staff discuss confidential patient information in public areas (Monthly)

  • Computer monitors positioned away from public areas or casual observation (Monthly)

  • Conversations with patients and/or family can be overheard (Monthly)

  • Phone conversations in secure area and can not be overheard (Monthly)

  • Dictation is completed where it can not be overheard (Monthly)

  • Screen savers are enabled on all computers that are unattended (Monthly)

  • Staff protects ID and password logons (Monthly)

  • Documents with HIPPA sensitive information are secure from casual observation (Monthly)

  • Paper records//medical charts are stored/filed in secured and controlled access (Monthly)

  • Confidential patient information is not left on unattended printers, fax or copiers (unless in secured area) (Monthly)

  • Confidential information is discarded in secure container off shredder (Monthly)

  • Voice mail settings are secure (Monthly)

  • Release of confidential informations is done per policy (Monthly)

  • Patient list and schedules with procedures are secured (Monthly)

  • Patient records are secured after hours (Monthly)

  • Authorized staff have access to confidential information based on minimum necessary for task (Monthly)

  • Open office doors unattended (Monthly)

HIPPA Challenge Questions

  • Who is next on the schedule in the (CT sim, Gantry, IBR2, IBR3, Fixed Beam)

  • Who is that (indicate a patient sitting in the waiting area or lobby)

  • What is the name of our cute little pediatric patient

  • What type of cancer does our pediatric patient have

  • SURVEYOR - Sit an listen, what do you hear? Patient information shared over the phone or in conversation.

  • SURVEYOR - What do you see? The area audited, can you see PHI on their desks or on PC screens

  • SURVEYOR - Who do you see? Are the patient's badges visible? Are the visitor's badges visible?

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.