Title Page
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Document No.
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Acute Care Discharge
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Light switch
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Solid/ Bio Hazardous Waste
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Purell Dispenser/ Catcher
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Paper Towel Dispenser
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Glove Dispenser
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Sink
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Counter Top
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Mirror
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Closet/Drawer/ Coat Hanger
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Sharps Container
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Emergency Light
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Call Remote
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Bed
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Phone
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Patient Table
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Drawers
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Dyna Scope Monitor
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Couch / Pillows
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Window Ceil
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Window
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Blind Pull cord
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Light
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Thermostat
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Chair
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Bulletin Board
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Television
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Check for visible soil on the curtain
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Door
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Door Knobs
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Check corners for dirt build up
