Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Nursing Station

  • 1. Clean and free of clutter

  • 2. No food present, only drinks with a lid.

  • 3. No patient care supplies left open on tables.

  • 4. Trash is not overflowing.


  • 1. Area/hallways are not cluttered.

  • 2. Handwashing supplies are available.

  • 3. Alcohol hand-rubs are available near patient rooms/in patient rooms and other areas as needed.

  • 4. Hand Hygiene is monitored for staff compliance.

  • 5. PPE supplies are available and are being used appropriately.

  • 6. Trash and linens handled per policy.

  • 7. No stained ceiling tiles.

  • 8. Patient care equipment cleaned/disinfected according to policy/company recommendations.

  • 9. Daily temperatures checks are documented appropriately for refrigerators.

  • 10. Fluid warming cabinets temperatures checked daily and are documented correctly. (Temp. not to exceed 140°F)

  • 11. No fluids kept if they are not in their original package.

  • 12. Sharps containers no more than 3/4 full.

General Infection Prevention

  • 1. All sterile supplies are dry with intact packaging at least 8" about the floor and 2" away for exterior walls.

  • 2. Staff has access to and are familiar with the MDRO list

  • 3. No out of date equipment/supplies present

  • 4. Humidity logs are filled out daily and are within normal range.

  • 5. Surgical EVS personnel terminally cleans all OR rooms at the end of the day.

  • 6. OR staff performs damp dusting in the morning before the first case of the day.

  • 7. OR staff performs case turnover cleaning in between cases.

Surgical attire

  • 1. Staff changed into scrubs at the hospital and are wearing clean surgical attire when entering a semi-restricted/ restricted areas.

  • 2. All hair is covered when entering a semi-restricted/ restricted area.

  • 3. Beards covered when entering restricted areas.

  • 4. Head coverings are disposable or are laundered by the facility.

  • 5. No visible jewelry worn by scrubbed staff.

  • 6. Mask is worn in the presence of open sterile items and equipment.

  • 7. Dedicated shoes or shoe covers are worn.

  • 8. Shoe covers worn as PPE removed and discarded immediately after use.

  • 9. Scrub Attire is launder after each daily use.

  • 10. Surgical attire removed before leaving the facility.

  • 11. Identification badges cleaned with low-level disinfectants.

Surgical Scrubbing

  • 1. Scrub is performed according to manufacturer's directions and aseptic technique.

  • 2. Scrubbed personnel do not contaminate themselves while gowning and gloving.

  • 3. Keeps hands and arms above waist level at all times.

Skin Prep

  • 1. Patient's received theraworx bath wipes.

  • 2. Hair is removed using clippers.

  • 3. Skin prep is performed according to manufacturer's direction.

  • 4. Sufficient drying time is allowed prior to draping.

Sterile Technique

  • 1. Sterile field is prepared close to time of surgery (<1hour)

  • 2. Sterile items are transported in covered/enclosed cases/carts

  • 3. Sterile packages are inspected for punctures, tears, and expiration dates.

  • 4. Draping is performed by at least 2 people and drapes are not lifted or moved after placement.

  • 5. Flash sterilization is only done in emergency situations.

  • 6. Counts are done accordingly.



  • 1. Flexible Endoscopes are placed in a drying cabinet or a storage cabinet.

  • 2. Endoscopes are hung up and do not touch the wall or floor of cabinet.

  • 3. All removeable parts are detached but stored with the endoscope.

  • 4. Clean gloves are worn when transporting the endoscope to and from the storage cabinet.


  • 1. Precleaning being performed at the point of use using a fresh cleaning solution.

  • 2. Exterior surface of endoscope is cleaned and suction is used through the suction and biopsy channels.


  • 1. Contaminated endoscope are transferred to the decontamination room as soon as possible.

  • 2. Endoscopes are kept moist but not submerged.

  • 3. A container or cart that is leak proof, puncture resistant, and large enough to contain all contents with the endoscope coiled in large loops.

  • 4. The cart or container is marked with a biohazard legend.

  • 5. There is a record of when the procedure is completed and when cleaning is initiated.


  • 1. All cylinders (oxygen, other compressed gas) are secured

  • 2. Empty oxygen tanks are kept separate from full oxygen tanks

  • 3. Fire extinguisher not obstructed from easy access

  • 4. No electrical panels are blocked

  • 5. Hospital furnishings/equipment are kept in good repair (No torn or soiled furniture, wheelchairs, mattresses)

  • 6. Countertops/doors are in good condition with no chipping to laminate

  • 7. No supplies stored under sinks

  • 8. Paper is not present on fire-rated doors

  • 9. Maintains the integrity of egress throughout the unit

  • 10. No space heaters present in patient care areas

  • 11. There is at least 18" of open space maintained below a sprinkler deflector to the top of storage

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.