Title Page

  • Site conducted

  • Conducted on

  • Prepared by

    Chart UR Number
  • MRN number of chart audited


  • The staff member who has high disinfected the nonlumen medical device is Tristel Wipe Competent

  • Staff member has not used Tristel wipes in > 6 months

  • Staff member has not used Tristel wipes in > 12 months

  • Has documented evidence of processing a minimum of 4 nonlumen medical devices per month to maintain their skill

  • Evidence found but not up to date


  • Device details and Serial number complete

  • No Serial Number

  • No device details

  • Date and Time processed complete

  • No Time

  • No Date

  • Incorrect information

Pre - Cleaning

  • Tristel PreClean Wipe used

  • Lot number and Use by date complete

  • No use by date

  • No lot number

Sporicidal Wipe

  • Two pumps of activator foam was used

  • Only one pump

  • Step missed

  • Scrunching of wipe with activator foam for 15 clock seconds

  • Step missed

  • Disinfection remaining on medical device for minimum of 30 clock seconds

  • Step missed

  • Traceability label has been completed with activator foam lot number and affixed to tracking book

  • No Label

  • Labels incorrect

  • Labels illegible

Rinsing Method

  • Tristel Rinse Wipe used

  • Lot number and Use by date complete

  • No use by date

  • No lot number

Destination Device

  • If device stored was patient’s notes label (from sporicidal sachet) affixed to storage box

  • Wrong labels

  • If device stored, was storage container cleaned, tracking book stamped with signature of person who has completed this

  • Tracking book not stamped

  • Signature of person not in book

  • If device used for a patient, patient label has been affixed to tracking book and Patient’s Notes Label has been affixed to intraop report

  • No label in Pt's notes

  • Sticker not correctly affixed to intra-op report

  • No Patient label affixed to tracking book


  • Person who has cleaned highly disinfected device has printed and signed their name

  • No printed name

  • No date

  • No time

  • No Signature


  • Device has been microbiologically tested within the past 3 months (IF required)

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.