Title Page

  • Hotel

  • Room #

  • Housekeeper/Inspected by

  • Conducted on

  • Location

Guest Room Inspection

Chart Review

  • All medical documentation is dated

  • All medical documentation is timed

  • History and physical fully completed

  • History and physical updated if done prior to admission

  • Does the history contain "inventory by body system" (review of systems)

  • Does the history contain the "chief complaint"

  • If H&P older than 24 hrs, but less than 30 days, is there a 24-hr update completed, signed and dated? Or an admitting note in progress notes to update recent events

  • Verbal Order/Telephone Order read back initiated

  • Verbal Order/Telephone Order authenticated

  • Approved abbreviations utilized

  • Nursing assessment complete ED & Outpt records, complete last section)

  • Pain assessed and reassessed

  • Restraints documentation completed HCP order)

  • Restraints documentation completed (RN initial assessment)

  • Restraints documentation completed (RN ongoing evaluations)

  • Is there a specific restraint order sheet correctly signed

  • Is there an individual order for use of restraints

  • Is there a specific restraint order sheet correctly dated

  • Is there a specific restraint order sheet correctly timed

  • Is there evidence of medication reconciliation at transfer of care

  • A handwritten operative progress note is entered immediately post-op

  • Pre-anesthesia assessment is documented

  • Examination of the airway is documented

  • A plan for general anesthesia is developed

  • Patient is re-evaluated immediately prior to induction of anesthesia

  • Is there a completed education record

  • Time out in OR to ensure that procedure, side, and sight are correct (verbal consensus)

  • Is there a completed plan of care

  • Was advanced directive question asked

  • Advanced Directive in chart

  • Informed invasive procedure consent obtained

  • Before informed consent is obtained, the risks, benefits, and potential complications are discussed by surgeon

  • Is there a specific procedural consent correctly signed in the chart

  • Is there a specific procedural consent correctly dated in the chart

  • Is there a specific procedural consent correctly timed in the chart

  • Is there a reason for blood transfusion

  • Is there a signed consent for blood transfusion

  • Blood administration documentation completed

  • The disclaimer statement is signed/dated by the attending surgeon (find an operative permit

  • Braden Risk assessment (skin) within 12 hours of admission

  • Medicare form is signed/dated when appropriate

  • Fall risk assessment is completed

  • General consent for treatment is signed

  • General consent for treatment meant is dated

Medical Record Documentation

  • Initial nursing assessment completed

  • Vital signs taken every 2 hours

  • Focused reassessment completed (pain, resp, cardio, neuro, psych)

  • Pain documentation completed

  • Restraint documentation completed

  • Influenza vaccine documentation completed (Sept. 23-March 31st)

  • Pneumococcal vaccine documentation completed

Guest Room Amenities

Marketing material

  • Guest directory

  • Report card on experience

  • Tourist brochures

  • Hotel food and drink menu

Night table/desk

  • 1 bible

  • 1 pocket folder with 3 envelopes

  • 1 am/fm clock


  • 3 hangers + 3 hangers with skirt clips


  • 1 ice bucket & poly liner

  • 1 waste basket

  • 3 ashtrays in guest room

  • 1 memo pad with hotel pen

  • 3 glasses

  • 1 telephone book


  • 1 frosted oval display tray

  • 2 bars of soap (1.25 oz)

  • 1 bottle of shampoo 22ml

  • 3 bath towels

  • 3 face cloths

  • 1 bath mat

  • Hairdryer

  • 2 toilet rolls


  • 1 coffee maker

  • 1 filter pack coffee

  • 1 filter pack decaffeinated

  • 1 tea bag

  • 1 condiment package

  • 1 iron

  • 1 ironing board

  • 1 fridge

  • 2 porcelain coffee cups

Guest Room Settings


  • Lights off

  • Heating set at 18 degrees or 70F

  • Windows closed

  • Television off with remotes out


  • Sinks off

  • Drain plugs open

  • Shower curtain centres

  • Shower head pointing towards wall

  • Toilet lid down

  • Bathroom door open

  • Light off

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.