Small House Visit - MD

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

House 101

• House Phone Operational?

  Yes

  No

  N/A

• Nurse Phones Operational?

  Yes

  No

  N/A

• Pendants/Pagers Operational?

  Yes

  No

  N/A

• House Computer Operational?

  Yes

  No

  N/A

• Nurse Computer Operational?

  Yes

  No

  N/A

• Office Printer/Computers Operational?

  Yes

  No

  N/A

House 105

• House Phone Operational?

  Yes

  No

  N/A

• Nurse Phones Operational?

  Yes

  No

  N/A

• Pendants/Pagers Operational?

  Yes

  No

  N/A

• House Computer Operational?

  Yes

  No

  N/A

• Nurse Computer Operational?

  Yes

  No

  N/A

• Office Printer/Computers Operational?

  Yes

  No

  N/A

House 109

• House Phone Operational?

  Yes

  No

  N/A

• Nurse Phones Operational?

  Yes

  No

  N/A

• Pendants/Pagers Operational?

  Yes

  No

  N/A

• House Computer Operational?

  Yes

  No

  N/A

• Nurse Computer Operational?

  Yes

  No

  N/A

• Office Printer/Computers Operational?

  Yes

  No

  N/A

House 106

• House Phone Operational?

  Yes

  No

  N/A

• Nurse Phones Operational?

  Yes

  No

  N/A

• Pendants/Pagers Operational?

  Yes

  No

  N/A

• House Computer Operational?

  Yes

  No

  N/A

• Nurse Computer Operational?

  Yes

  No

  N/A

• Office Printer/Computers Operational?

  Yes

  No

  N/A

House 102

• House Phone Operational?

  Yes

  No

  N/A

• Nurse Phones Operational?

  Yes

  No

  N/A

• Pendants/Pagers Operational?

  Yes

  No

  N/A

• House Computer Operational?

  Yes

  No

  N/A

• Nurse Computer Operational?

  Yes

  No

  N/A

• Office Printer/Computers Operational?

  Yes

  No

  N/A